219 ‒ Dialectical behavior therapy (DBT): skills for overcoming depression & emotional dysregulation

hey everyone welcome to the drive podcast i'm your host peter etia hey sharin it's great to finally meet you not in person but uh better than being on the phone i guess yes same here so um you know people on this podcast have probably heard me in a couple of episodes reference this thing called dbt uh i've never really gone into much detail about it but it's something i've wanted to obviously have a dedicated podcast around and now we're finally going to get to do that so i mean i guess maybe we can just start by kind of defining what it is a little bit before we get into its history uh its founder your your involvement and things like that so if you're at a party and somebody said shireen i i heard that you know you're a dbt therapist and a practitioner uh can you tell me what that is what would you say sure so dbt stands for dialectical behavior therapy abbreviated dbt and it's a form of therapy or a form of talk therapy that is largely inspired by cognitive behavioral therapy also abbreviated as cbt so we often say that dbt is a form of cognitive behavioral therapy that was designed for individuals that have complex mental health problems and originally designed for individuals that are suicidal or self-harming and who may meet criteria for a disorder called borderline personality disorder so i so at its simplest i would say it's a form of cognitive behavioral therapy that was designed for more complex people or presentations but then of course there's a lot more nuance uh beyond that yeah which we'll we'll certainly get into um maybe give people a bit of background on what cognitive behavioral therapy is i mean that term i've heard a lot but truthfully i don't know much about cbt outside of cbti which is cognitive behavioral therapy for insomnia which we have referred i would say over the past five or six years probably a dozen of our patients to cbti practitioners and i think i can say without exception it has always proved to be incredibly valuable not just incrementally valuable but incredibly valuable but that's that's the very limited experience that i have with with cbt is through that that one narrow lens is there something more broadly we can say about cbt that then allows us to contrast it with dbt yes so cpt it refers to maybe a class of uh talk therapy and could often be used to contrast uh with other kinds of talk therapy but some of the distinguishing features of cognitive behavioral therapy is that it's present focused so focused on what's happening for people right now in terms of the problems they're experiencing and less focused on one's history um one's childhood uh less focused on the sorts of things that have led to the person experiencing the problems that they're experiencing so it's present focused and it's as the name implied it's focused on um working with thoughts and behaviors that go along with the problems that people experience so in cbti for example it would be you know what are the thoughts that are contributing to your insomnia uh and how do we work on modifying or changing those thoughts that you're having in order to increase the likelihood that you fall asleep let's or stay asleep what are the behaviors that you do that promote sleep what are the behaviors that you do that get in the way of sleep and how do we modify that so at its most concrete level it really is working with thoughts and behaviors that in the present that are contributing to your problems right now so it's very much an active problem-solving approach and i think what is um with people who don't have a lot of experience with therapy or receiving mental health treatment they might have an idea based on the media or tv or movies that the best therapy is one where you just go in and talk about whatever's on your mind and cbt and similarly dbt is much more structured and and guided than that and the other the other distinguishing feature i will say about cbt and dbt is that it's evidence-based meaning that we construct treatments in a way that we could measure its effectiveness and if we find that something is not effective for people then it's not likely to stay in the therapy that's that's our goal anyway is to be as empirical in our and scientific in our approach as possible so how long has cbt been around as a discipline i would say it emerged you know probably the figure that is associated with the beginning of cbt is a man named aaron beck who died last year i believe at the age of 100 and so he or something like that number um i would say it was probably the 60s in which he first started developing his form of cognitive therapy he was trained as a psychoanalyst and was seeing that it wasn't all that useful for a lot of the patients that he was treating in psychiatry and so he started developing an approach that was much more about changing the way people thought about themselves and others so let's talk about marsha who is obviously a very marcia linhan who's a you know uh i i think it's safe to say really the creator and founder of dbt is that a fair statement yes for sure um so tell me about her journey presumably she had tried cbt both as a patient and maybe even as a therapist before realizing that there was a way that it could be improved upon for at least a subset of patients and or a subset of problems would that be kind of a fair statement yeah so the origin story of of dbt was that originally marcia set out to apply what might be standard considered standard cbt to folks who are chronically suicidal and um this was you know perhaps beginning in the 70s uh she was receiving advanced training at stony brook in new york at that time stony brook was considered one of the premier places to learn and apply behavior therapy and back in the days of the 70s uh 80s there was really the heyday of behaviorism and the idea was in some way in many ways oversimplified but the idea was that we could treat any mental health problem with behavior therapy in very few sessions um just by applying these you know standard principles of what we know about behavior change can you by the way can you give me an example of what that would be so does that mean that if if a person was clinically depressed and came in and they were suicidal what would the cbt approach have been in the 70s or 80s to address that concern well i might if i can come back to depression and suicide in a minute but i might start with anxiety disorders because this is actually uh what um behavior therapy and cbt was probably most uh prolific about in those days and the idea was that you could have somebody who came into treatment with a fear of something a phobia it could be something like a fear of heights or a fear of spiders or it could be a fear of social situations social anxiety and the behavior therapy approach to this or the cognitive behavioral therapy approach to this would be to teach people competing thoughts so rather than thinking this thing will kill me um i can learn to have thoughts like um i can tolerate this uh this might be difficult but i can i can handle it or even have thoughts like this is not going to kill me um but those thoughts were only one part of it the other piece of it was the more behavioral piece which is uh exposure basically saying that how you're going to get over your fear of spiders is not to talk about it every week for an hour with somebody but it's actually going to be coming into contact with spiders repeatedly over and over again so that you learn that uh you can handle it uh but you also learn that the feared outcome is not going to occur so so that was uh so change your thoughts and get exposure change your thoughts get exposure exactly and the getting exposure is changing your behavior because you want to run away or avoid and instead it's saying come into contact with approach something that you want to avoid and so what they were finding in these you know early days of applying cbt is saying uh you know people may have gone to psychoanalyst uh psychoanalysis which was the dominant paradigm of therapy in those days and and by the way this is almost exclusively a rich white person issue when i'm talking about you know who is receiving treatment for mental health problems that's what i'm talking about back in those days um largely and so people could go to a psychoanalysis psychoanalyst and talk about their fears for months and years and not necessarily do better with them and so cbt comes along and says actually we could do this sometimes depending on what the fear is in one session there were people who would do like a three-hour session to you know quote-unquote cure somebody of a phobia and and they were finding that it that it worked and so then you say okay how do we take those principles to something like depression uh and this is what aaron beck started to do with cognitive therapy more was noticing that people who have depression tend to think in very particular ways um they have uh negative um interpretations of almost everything right and also about themselves about their future about others and so a cognitive behavioral approach to depression would be about working on changing those thoughts to be more balanced and evidence-based and then also the behavior change that goes along with depression is usually about getting active so when somebody is depressed the the tendency is to retreat shut down avoid and the behavioral treatments for depression would be to get people activated uh and to solve the problems that are causing the depression whether it's unhappiness with a job uh unhappiness with a relationship and and work on targeting the problems that are causing depression in a systematic way how successful was it you mentioned earlier that evidence is a very important part of this um how were they able to tally the results and determine if their intervention was in fact better than the standard of care at the time right so uh the history of psychotherapy trials is largely based on a paradigm known as randomized clinical trials where you would recruit individuals who meet a certain inclusion criteria say somebody meets the diagnosis for depression and then you would randomize them to either say receive you know 12 weeks of cognitive behavioral therapy or receive nothing or receive a treatment as usual or standard of care and then evaluate outcomes over time and with things like uh depression and anxiety disorders there are these standard measures that are you know popular within our field where we have developed benchmarks for what uh we're trying to get to you know what might be considered a success and i would say that in general that the trials for cbt for things like depression and anxiety are are overwhelmingly positive meaning that most of the trials especially in the early days when you were comparing cbt to nothing or you know treatment as usual found very large effects uh for cbt um in those settings now i think uh where we see or where we'll come back to marcia emerging is recognizing that of course uh none of these treatments were 100 successful um for everybody and more than that is that when you look at these studies and you see who were these studies done with the inclusion criteria meaning what allowed somebody to be in the study were often quite narrow for example with a depression study the person might have to meet the criteria for a diagnosis of depression but not have suicidal behavior so people with suicidal behavior may be excluded from a lot of those studies which makes sense from a research point of view in some contexts but in other contexts does it make sense because of course we know that a lot of people who experience depression um are also suicidal so if you're removing suicidal people are not allowing suicidal people to be part of this research then we don't know ultimately if the treatments work for those populations so when did i mean marcia as a young girl i think was diagnosed with schizophrenia is that correct and was treated with electro convulsive therapy and all sorts of things that are still used today but probably not as frequently and probably with a bit more uh particular attention to the use case probably used more liberally than i'm guessing so marcia was a teenager i believe at the time that she was receiving a lot of treatment and this was in the late 60s if i'm no wait if i'm remembering correctly what uh when she was born now that i'm thinking about it but uh it was before cbt was really in the picture and she was sent away uh hospitalized for being suicidal and chronically self-injuring doing a number of things to cause physical harm to herself as a way of relieving emotional intensity and overwhelming emotions and so at the time there was not a lot of treatment options that were available and the medical model was to treat with really strong meds uh you know antipsychotic meds at the time or to use something like electroconvulsive therapy and so those were the treatments that she was exposed to from a very young age in addition to therapy but the types of therapy that she was receiving at that time uh were unlikely to be um you know anything like the cognitive behavioral treatment we know today so how did she find her way from being almost institutionalized to eventually you know getting an education and herself becoming a therapist what was that journey that went from that teenage girl to kind of the the person who created dbt yeah so she has uh written about this in a memoir as well as uh described it in a piece in which she uh in the new york times which was a piece where she kind of came out to the world as having been someone who experienced her own struggles uh significant struggles with mental health and i say that as a preface because uh for that article in the new york times came out i believe in 2010 2011 so for most of her career she was not forthcoming about this her own personal struggles she would tell people that were close to her knew her students i was one of them knew about this experience but she wasn't public about it and she would long say that the reason for that is because she wanted dbt to be judged on its merit empirically she did not want um uh dbt to be judged on her personal story alone she she wanted this to be a scientific treatment that that lives and dies by its outcome she would say so so um so when she would talk about how dbt developed um to the public is she would talk about it in um leaving out this earlier part of her own history so the earlier part of her own history that she describes is that she she had a spiritual moment um when she was in one of these institutions and the spiritual moment was that she describes experiencing god in a very dark moment of her own life and in that moment she realized that she could she felt the love of god and felt that she could serve this purpose in life which is to get out of hell her own experience and then to work uh her entire life to get other people out of hell and that was how she took this spiritual experience and developed her life's work based on that now another reason why she did shireen at that time i would say um as best i remember in her early late teens or early 20s kind of profound to be to follow through on something that you know you could argue well god you were still so young when that was happening and and was she at some point here diagnosed as having a borderline personality disorder as well or is that something that is more retrospective where it's sort of like looking back she was probably misdiagnosed as having schizophrenia i mean what what was the state of understanding of her her actual condition uh so i believe that she was probably you still see this today but when people are unclear about how to explain someone's problems they get given almost every diagnosis in the book and now this would have been before the criteria that we now know is borderline personality disorder being defined and the way it uh is most well known um would have started in the third edition of the dsm which uh came out in about 1980 so the criteria that we have now to define borderline personality disorder was not the same as when she was receiving treatment so i believe that she had a number of diagnoses attributed to her um it's i can't remember it's quite possible that borderline personality disorder was one of them um because of course that's also the diagnosis that they give people when they don't know how to treat them uh and so it wouldn't surprise me and what what are the criteria tell tell folks what borderline personality disorder is today what do we what do we know today yeah so borderline personality disorder is considered a complex mental health disorder that is defined as meeting there are nine criteria of borderline personality disorder as defined by the dsm and in order to meet criteria or to have the condition you have to endorse five of the nine which actually means that ultimately it's a really heterogeneous disorder because there's all these different combinations and different ways in which one can meet criteria uh what one of the things that marcia did um was to restructure the different criteria borderline personality disorder in a way that that perhaps is more understandable and also makes more cohesive sense and to say that it's a disorder of dysregulation across a number of different domains so the core domain of dysregulation that we see in borderline personality disorder is what we refer to as emotion dysregulation and this is largely defined by people's experience of emotions as feeling like um they have very intense emotions they don't feel like they can control their emotions very well their emotions change very rapidly so that's referred to as affective ability that the emotions will go from intense sadness to intense shame to fear to joy you know very quickly and seemingly without a lot of uh reason so emotion dysregulation is part uh and considered core to the disorder of borderline personality disorder and then these other domains of dysregulation stem from emotion dysregulation and include behavior dysregulation so not having control over or feeling like you don't have control over your behaviors this is associated with a lot of impulsivity and behaviors that go along with impulsivity so substance use reckless spending impulsive sexual behavior uh impulsive driving you know behaviors that are experienced as impulsive and potentially could cause problems for the person impulsive eating uh is another domain i mean it sounds like there's quite an overlap at least in some of those with bipolar disorder right bipolar one where you could sort of see i don't know about the effective lability but certainly the mania side of it sounds like it might be consistent with some of that dysregulation i'm guessing that's what makes psychiatry so difficult is you don't have biomarkers you don't have imaging scans that give you diagnoses right right uh we don't and so there is you're right a lot of overlap and actually probably the ones the overlap that is more consistent or difficult to discriminate is bipolar ii because bipolar one is associated with the depression longer longer lengths of either a pure manic state or a pure depressed state bipolar ii might have manic states but it is shorter in duration or might not be you know super manic right as high and so that's that's often really hard to discriminate from um somebody uh who has borderline personality disorder and generally what we're talking about with with bpd as opposed to bipolar is that we actually see the mood changes happening more frequently uh within bpd than with um bipolar ii but i i'm probably oversimplifying but that's what i would be looking for if i was trying to assess the difference between the two a person with uh bpd um what are what are the challenges that they face in the in the world right if this is a let's just assume this is a person of totally normal intelligence and other all all physical capabilities are fine and this is sort of the one issue this one psychological issue how does it manifest itself for that person when they're in school when they're in college if they get married if they have kids like help help us understand how this condition makes life more difficult for the individual and and those around them yes so one thing i'll say is that you rarely will see this condition in isolation of anything else and again this speaks to one of the complexities of trying to study psychiatry that i think on average people who who meet criteria for bpd have three to four other mental health problems at the same time so they'll also meet criteria for depression or an anxiety disorder or a substance use disorder or an eating disorder and those things aren't stemming from the bpd these things are we believe independently there as well well i think it depends on who you ask because i would say as somebody who is trained mostly behaviorally i would say the diagnosis matters less than how we conceptualize these problems and to that point i would agree with you we could say emotion dysregulation is is central to all of those things but the diagnostic system as we currently have it does not allow for that so they would say you know if somebody meets criteria for these other disorders they also have these other disorders right so how somebody with borderline personality disorder you know lives their lives i would say um it's complicated because on the one on uh and it ranges on one end of the continuum you know we see people who have uh severe problems associated with bpd such that they they struggle to hold on to a job um so they don't work and they're on disability or receiving social security they um they can't maintain relationships so they're they're very isolated and why is that why why are relationships blowing up and why are they not able to hold down a job what's the fundamental issue or fundamental issues that are impairing them from a dbt perspective we would say that it all comes back to difficulty regulating emotions so that if i experience intense emotions that i feel like i can't control when i get angry i lash out when i get scared i run away or avoid or i have a motion just one of the criteria that goes along with bpd that you could see as tied with emotion dysregulation problems is what's referred to as fears of abandonment so a person with bpd often will have a lot of fear that a person that they love or are close to will leave them and if i am in a relationship where i am afraid that the other person is going to leave me all the time that may cause me to behave in ways that are frantic chaotic and actually um paradoxically have the effect of causing the other person to be more likely to leave right texting the person calling the person relentlessly um if if a person doesn't come home or call at the time that they say they will um you know having the experience of feeling like i'm losing it because i don't know where that person is or perhaps they've they've left me as a result if i have bpd i experience intense fear intense shame intense sadness and now i don't know what to do with this intense behavior and i may self-injure as a way of relieving that emotional intensity or i may threaten suicide as a way of getting the person to come back to me and maybe i'm doing this without even having awareness that that's the effect of my behavior i just know that in this moment i don't know what to do i feel entirely out of control and i need to do something to to fix it in this moment what is the um mortality of bpd i i i was very surprised to learn recently that um anorexia nervosa has probably the highest mortality of any psychiatric condition i would have guessed depression presumably um but where does where does bpd stand in terms of mortality either through self-harm and neglect potentially or obviously suicide i sometimes get into the weeds a little bit about this and when as a as an academic and psychologist what i find and someone who studies suicide i review a lot of manuscripts and and grant proposals and i am always um uh saddened and amused when i see people you know write about a disorder and say this disorder has one of the highest rates of suicide because if you look at it it seems like every disorder has one of the highest rates of suicide and i think it's because we don't know how to study this very well honestly we we don't know how to um how to determine of the people who die by suicide what are the mental health conditions that they had and what is the relative risk according to these different disorders yeah well especially when you overlap because as you said earlier if a person with bpd also suffers significant depression if they commit suicide are we attributing that to depression or to yeah so so no i think my question more broadly is knowing that one could never tease that out how risky is it for an individual understanding all of the comorbidities that that tend to cluster with it i will say it's very high and one way in which i can answer this is that one another criteria for for bpd is uh repeated or chronic self-injury or suicide attempts and upwards more than 75 of people and in some studies 90 to 95 percent of people who meet criteria for borderline personality disorder engage in self-injury um or have made more than one suicide attempt in their lives and this tells us a couple of things um one is that there that that on its own is considered a very high risk behavior because people who engage in self-injury even if they don't intend to die there could be accidental death as a result of self-injury what are some examples i mean people probably think of the most common examples of people cutting themselves or burning themselves what are some other examples of self-injurious behavior that people engage in um head banging uh or um punching or hitting oneself there are multiple forms of of cutting that include you know different objects to cut but could also be people um really intensely scratching themselves to the point where they uh draw blood there's overdosing is considered a form of um self-injury uh especially if it's um or you know you have to determine is this with intent to die or not but but there are people who overdose without intent to die um as a way of hurting themselves there's also um you know more rare but other forms of self-injury may involve ingesting toxic substances uh et cetera so um this has also i think evolved over time or we didn't know how to study it very well over the years because even in my career i feel like 20 years ago when we were talking about self-injury we were talking much more about things like cutting or burning and i feel like as there have been more people interested in studying self-injury we're also finding out about other ways in which people cause harm to themselves and then there's all sorts of debates about whether this you know is considered self-injury or not because some people might say i i have binge eating or i overeat and i and i do that intentionally even though i know it's causing harm to myself whether we classify that diagnostically as self-harm or not um is one question but whether a person considers themselves actively doing harm to themselves that's that's another question what's the male female split in in bpd yeah so that's another thing that's changed over time it was long thought to be a female disorder and um and there's all sorts of reasons for that a lot of them are sexist now we see more studies that indicate that there are roughly equivalent rates among men and women however there's still a bias a diagnostic bias for tending to diagnose women more often as bpd intending not to diagnose men with bpd so does that mean under-diagnosing men over-diagnosing women potentially i think so i think the under diagnosing of men is has been shown in a number of studies and it appears that men have to be more severe in order to receive the diagnosis than than women whether women are over diagnosed i'm not sure but i i think it's very rare that you would see a psychiatrist or a medical professional do a diagnostic assessment i think it's much more likely that they base that diagnosis on is this person difficult in some way so when you look at the twin concordant studies of things ranging from autism to depression you see a very strong genetic component to these things do you have a sense of how strong the genetic link is for bpd presumably based on these identical twin discordant studies identical twins raised separately and looking at the prevalence um how much of this is genetic and then how much of this is environmental where life events trigger a susceptible individual to manifest the traits so i don't know the the data off the top of my head about the twin concordance but i would say there's a general understanding that there there is of course a genetic component to this disorder and i would say that the the dbt framework is one that has a model for explaining how bpd develops which we can probably get into but that speaks to the the fact that there is both a genetic and an environmental component um to the development of the disorder so let's go back to marcia in her journey so she has this you know literally come to jesus right so she has this kind of epiphany in her late teens or early 20s which it sounds like you know puts her on a different path potentially saves her life it's still a long way from there to where we are today so walk us through that journey right so this is where it picks up in terms of the story that um is part of the the development of dbt story so um now leaving out her own personal history you know marcia went on to get a degree in i mean i should also point out that i think one of the factors that led to marcia being able to do this is that i think she's hands down a genius and so that was probably um uh despite her really difficult um experiences she had this amazing capacity for you know thought that helped her i'm sure in numerous ways including developing this treatment but so she went on to get a degree in in social psychology a social psychology phd which is a little known fact about her that she's not a clin she doesn't have a degree in clinical psychology but she got her social psychology degree but then decided that she wanted to get clinical training and that's what led her to this um training experience at stony brook which is where they were um doing a lot of work on theory and treatment related to cognitive behavioral treatments for a range of disorders and at that time nobody was studying cognitive behavioral treatment for suicidal populations and so marcia decided i want to take what we know about cbt that seems to be hugely effective for all these disorders and i want to take all that we know about cbt and just plop it into treating chronically suicidal individuals the way she reports it is saying she wasn't interested at that time in diagnosis she just wanted to work with people who chronically experienced urges to die and so that's what she attempted to do and by her accounts um this quickly blew up and just because just for timing this is kind of i'm guessing this is now the early 80s yes okay late 70s early 80s when she did her fellowship there and do we have a sense of how she is treating herself at this point in other words how is she regulating her own emotions are the tools of cbt things that she is finding helpful for her own self-care this is a great question and i'm not sure i know what the answer is and what's interesting is that it's it's um i think that what marcia did was she took a lot of her own experiences and then she was able to translate that into cognitive behavioral terms whether she and and which led to the development of a lot of the skills in dbt that she developed for people whether she was um thinking at the time about applying cbt to herself i don't know but i think that that's uh what she ended up doing yeah by developing nature so she sort of became the index case right you know she was sort of not necessarily thinking at th this way but she was working out the tools of how do you transition you know i sort of liken that to what bruce lee did i don't know how familiar with bruce lee but you know um you know most people sort of know him as you know kind of a movie star in martial arts but but he was far more relevant in creating a system of martial arts called jeet kune do took from over 30 different other styles of martial arts and and in his words took what was useful and discarded what was useless and sort of created a new system with a very particular goal by the way so he had a very clear objective in what jeet kune do was to be about um and it in some ways it's almost like that's what marsha was doing on herself right yes on herself and also in her treatment development work which is you know a very iterative process like let me try this does this work i'll keep it does it not work i'll throw it out if it works what is it how do i define it how do i write about it in a way that other people can do it and and you know put it all together in a package again i think this speaks to how brilliant i think she is that that she could do it but it it it does align with what you're describing which is really um and what's i think really exciting about treatment development work is this whole process of of of figuring it out as you go and then trying to replicate it um and really using the the client's experience to say is is this having the intended effect so i interrupted you but let's go back to marcia stoney brook and finding out that cbt in its current form is not helping suicidal patients at least not to a level that she's feeling is successful right right so what she uh again this is second hand so i just tell the story as though i'm her but what she would uh report is okay i go into my session with somebody and i asked them about what are all the problems that you're experiencing that it's causing you to feel suicidal and the person would say uh i hate my job you know i hate my relationships uh i i don't have any pleasure in my life whatever those things are and marcia with the cbt lens would say no problem uh we can figure this all out we'll just you know take all of your problems we'll put them on the list we'll systematically go through each of your problem one by one which we'll solve and uh we'll we'll figure this out in no time and the way she reports it is that she she did that feeling all the hope in the world and the reaction that she got was totally unexpected which is people saying you have no idea you have no idea how bad my problems are if you thought that these are things that are easy to solve you are sorely misunderstanding the depths of my problem you clearly don't understand anything about me or my situation if you think that these are something that things that could be easily solved and more more than that if these were easily solved i would have solved them a long time ago you have no idea how much i'm suffering right you don't get it so this iterative process was like okay this blew up right clearly uh this isn't working the way i intended and so the next uh piece of her story is she would say okay that's not working i need to figure out what's going to work and she said she took kind of the other perspective and she said okay what they're telling me is that i don't understand the depths of their problems and maybe that's true and so what i need to do now is is tell them and work with them to completely understand and so she would go into her sessions with again you know people who are chronically suicidal and say you're right your problems are too difficult you've had long-standing um experiences with trauma you've been treated terribly your whole life uh you have a number of obstacles that may prevent you from getting the job that you want or the relationship that you want and perhaps what we need to do is work on accepting your life you know as it is um and and finding joy in that but but accepting you know the life as you as you have it and let go of you know trying to solve all these problems and so that was her next step so so this is the this is the epiphany that of course anyone who's done dvt knows is radical acceptance well it wasn't quite labeled that yet no no yeah but was this kind of the precursor of what we would now describe as is that what i would say yes i think it could be the precursor but it was missing something because what she would say is like this is the acceptance piece but when she tried it thinking oh this is what people want you know they're saying i can't solve their problems and so clearly if i communicate that i understand how difficult things are and we can work on accepting it uh the reaction she got then was what there's no hope how can you say that i should just accept this my life is miserable as it currently is you know if i accept this there's no hope i should just die uh you again you don't possibly understand you know everything and this was the um you know dbt stands for dialectical behavior therapy we can talk about dialectics um but this is what turned into the the idea of this primary dialectic in this treatment which is the dialectic between change and acceptance and and figuring out how how do i as a as a therapist as a treatment provider straddle this line synthesize this because both of these are important we need to work on solving the problems in your life that are causing you such distress and misery and we also need to work on accepting your life as it is and accepting the things that that we can't change um about our lives but how do we do that in a way that is palatable to the person on the on the other end and in a way that says uh that conveys hope um that things could change and so it's about synthesizing those two elements and i think it's the it's a synthesis of those elements that lead to things like radical acceptance and other uh components of the treatment so this is probably a great time to double click on what dialectical means because it is i don't know i i'm not sure if it's innate to us right i think it requires some practice yeah i was listening to some interview the other day where somebody just simply said humans don't like contradiction and i think that that's true we don't like contradiction and so dialectics is really the um at least i'm by the way i'm no expert in dialectical philosophy as you know as marx um initially wrote about it i'm i'm more a student of dialectics as it informs you know my life and my practice but uh dialectics is this understanding that there is contradiction and opposition and tension in everything uh and therefore we can't avoid it um and the more we try to avoid conflict and tension um the more likely it is that we're going to see conflict and tension and so dialectics is at least again in the practice of dbt is the practice of recognizing tensions as they exist polarization as it comes up and then striving to find what is valid about both sides or both sides of the tension and seeking to find a synthesis some new argument or new statement that recognizes um and adopts the validity in the two opposing sides this might be a reasonable time to jump forward and then i want to come back because i love this sort of story but if you've if a person listening to this or watching this has ever kind of gone through dbt then they're familiar with the workbook right you're doing this in a very structured way and one of the first images in the workbook is the two intersecting circles of wise mind and emotional mind do you emotional mind and reasonable sorry reasonable mind yeah why is mine being the intersection yeah so um maybe use you want can we use that as an example of dialectical synthesis where you have those two minds uh intersecting and then that that union or intersection of them being the wise mind and how do we find those but but again contrasting it with with uh sort of emotional and reasonable mind yes so i think you um that's exactly right that that is an illustration a key illustration of dialectics at play is this is this notion of wise mind and the way we and wise mind being a skill in the workbook that we teach people as something that we um are striving to uh to access wise mind more often in our lives and that that accessing wise mind involves synthesizing these these two tensions potentially or polarizations known as emotion mind and reasonable mind so we emotion mind is the idea that a state in which we are completely controlled by our emotions uh so when we're angry it could be lashing out at somebody it could be engaging in physical violence it could be threatening physical violence it could be slamming doors uh it could be quitting things you know all the things that we might do when we're when we're being controlled by the anger we're experiencing reasonable mind on the other hand is when we're controlled kind of by facts and logic and emotions aren't really um uh we're not aware of or experiencing any strong emotion and you could you could imagine or you can envision the tension that exists between these two if you've ever been in a motion mind having an argument with somebody in reasonable mind uh or vice versa because um that happens a lot i think it has happened in my marriage it probably happens a lot uh across many people's marriages where one person is in a motion mind the other person is in reasonable mind and that's a recipe for uh you know a really strong conflict so wise mind is saying okay what can i um what's valid about the emotion that i'm experiencing here uh what's valid about reasonable mind that i'm experiencing here and once a synthesis so a silly story that we might tell to illustrate a wise mind or emotion mind is you're walking down the street and you pass by a pet store and in the window are a dozen puppies or if you're a cat person imagine a dozen kittens okay uh emotion mind takes over and says get them all i want all the puppies every single one of them because this one is cute for this reason this one is cute for this other reason oh my god they would be so happy together and i would be so happy if i had all these puppies in my life i want them so emotion mine says get all the puppies reasonable mind says oh my gosh dogs are so much work you have to walk them three times a day they're expensive you have to get all this equipment uh you have to get a veterinarian you have to restructure your time so that you spend more time with the dogs or not you have to you know reimagine your whole life around that so reasonable mind might say no puppies uh puppies are never for you right so what does wise mind say well what's great about even teaching this as a as an idea is that wise mind is not um or and a synthesis a dialectical synthesis is not a compromise it's not a halfway point because if i were to say that then wise mine would say get six of the puppies if there are 12 right uh and that makes no sense as a compromise or as a synthesis because it's not seeing the validity in both sides so what would wise mind be that would vary depending on the person because for some people a wise mind decision would be to bring home a puppy for other people a wise mind decision would be to say now is not the right time for me to have a puppy but i am going to do x y and z in order to increase the likelihood that i can have a puppy in the future wise mine might be i have the perfect scenario now i can bring home two puppies and we will live happily ever after so it's going to to vary but the idea of finding this synthesis is about um seeing what's valid and true about both ends of the or both of the sides and then trying to figure out um what a synthesis could be does that make sense it does it really does of course and um i think one of the things i'm struck by when i look at the the notebook the workbook that we use in dbt is how much is in it and to think that this is sort of the work of largely one individual and obviously it's been iterated on but it's really kind of remarkable so can we kind of go back to the story of some of the earliest insights she had treating some of the most in need patients and how she basically then realized she couldn't do what she was doing under the umbrella of cbt and needed to make this change from the cognitive to the dialectical and create another form of behavioral therapy which again is it's really a it's really a kind of remarkable um thing to to realize given how relatively recent this is i mean this is something that's happened in the last 30 or 40 years agreed yeah so i think you know getting back to where she was in terms of realizing that you know if i push for change too hard disaster happens if i push for acceptance too hard disaster happens what can i do to you know find um the middle how do i balance these two things and again part of the the lore of the story of dbt was that she was um writing about this idea of balancing change and acceptance and these were the days where she would you know write up notes either handwritten or on a typewriter and hand them over to a secretary who would you know type them up or revise them and uh her story is that the person her her assistant that was working on typing this all up came to her one day and said my husband is a graduate student in philosophy and uh we were looking at this and we think that what you're describing actually is something that he he studies uh and is called dialectics so according to marsha she didn't know anything about dialectical philosophy um as she was iterating this treatment and this was one of those happenstance moments that um that came to her and then of course she sought out readings uh descriptions of dialectical philosophy and saw yes that is exactly what she's thinking and that dialectical philosophy informs a lot of science uh and scientific thought and so um actually worked well within the the paradigm of you know the development of of cognitive behavioral treatments so so that's where you know dbt started to take form however if if you're familiar with her books you know that her original treatment manual that was published in 1993 uh including the and and also the original skills workbook that was published in 1993 says on the cover cognitive behavioral therapy for i wasn't aware of body disorder the the newer edition says dialectical because she was told at the time by the publishers that nobody will know what this means and nobody will want it uh and i think that may be true it's it's possible that if it was called dialectical behavior therapy on the cover of the book back then it would not have actually been as popular as it is now now of course we can put dialectical behavior therapy on the cover of any book and um and people will see the value in it but i don't think that was true then when did she develop kind of her own sort of interest in zen philosophy and the practice of mindfulness which also is a very important muscle that one kind of develops as they move along their dbt journey was this something that had been more long-standing with her so i think that this was all happening around the same time that she was her own interest in you know marcia grew up in a catholic family identified as a very uh religious person identified as saying that at one point she thought she was um going to become a nun uh and so this was a large part of her upbringing when and also was part of that spiritual experience that she had personally but i think she also uh realized that and another reason by the way that she didn't want to come public with her story early on is that she didn't want the lesson to be oh if you want to get better you also have to have a spiritual experience instead what she wanted to figure out was how do i um how do i operationalize for lack of a better word this spiritual experience so that other people could experience it as well and so i think that was going on in her mind at the same time that she was um interested in her own spiritual development and um and learned more about zen and became a student of zen buddhism and saw that they they all connected and came together because ultimately how she translated that personal experience um is into this idea that you mentioned earlier of radical acceptance can you radically accept this moment this situation yourself exactly as it is and if you can experience that radical and complete and total acceptance you can experience joy you can crack open the moment of joy she would say yeah i mean there are some things where you know shireen that's i get it right like you're stuck in traffic right so you're you're you're you're supposed to be going somewhere and let's pretend it's some place that matters right it's not just like a dinner reservation let's say it's your kid's sporting event or you going to the airport and it's a flight and you if you miss it it's going to really wreck things up and there's nothing you can do about it you're stuck in traffic there's an accident a mile ahead and that this is the way it's going to be walk me through what you would say you know your your your patient now is in the car and you're sitting with them in the car and they're understandably getting very flustered at the situation walk me through radical acceptance in that situation how are you helping that person go through the you know can you fix this problem are you accepting this problem can you change like going through all of those layers for that specific type of problem yes and i've been in that problem for myself so i understand yeah so you know um what i would say as a precursor is that when we're experiencing suffering however you define that suffering if you were to look at it more deeply you would say the vast majority of the time that we're experiencing suffering it's because we're thinking about something that has already happened ruminating wishing it hadn't happened mulling something over whatever it might be or you're thinking about something that may happen in the future and that actually if you just experience this one moment uh and let go of the past and the future that alone might reduce your suffering a ton but we could say you might experience pain in this moment because this moment might be painful but we're not adding on we're not adding on all of these things that actually increase our suffering so in this moment when you are stuck in traffic you can't undo the decisions that you made that got you to this point right because of course we're saying things like oh if only i had taken this other road or if only i had left 15 minutes early or we think all these stupid people on the road if only they had done something different right so that's those are all fantasy thoughts because they're all not reality of this moment so i would say how do we reduce our suffering in this moment is to say i can't change any of that for today in this moment this is what it is um and what happens you'll see actually i'm holding my palms up right now as i'm talking because i associate holding my palms up with this idea of willingly accepting this moment which is uh this is the moment that i'm in yeah it's sort of a surrender posture yeah yeah in a way it's the surrendering willing this is the moment i'm in and what happens if i just just as though it's easy but what happens if i accept that right now there is nothing i can do to change this right now i think the other piece to this is and this is why it's not just about acceptance because i would say if this is something that happens a lot right if you often find yourself in situations whether it's traffic or something running late or something like that then we absolutely want to figure out how to prevent this from happening as much in the future but in this moment when you're there you can't do that so in other words in the moment of crisis you don't really want to be problem-solving around how can i avoid this the next time how do i avoid this crisis again in the future when i'm at a 100 or a 90 of distress i'm not going to be able to effectively do that now obviously so much of what you're saying sounds very familiar to anybody who has practiced mindfulness or vipassana or one of its derivatives in forms of meditation um we've had a couple of podcasts that have have sort of gone into that and you know when the goal of the practice is to help you identify thoughts and to separate you from these thoughts and so in this individual i mean there's probably nothing as you say in this exact moment that is particularly unbearable but the thoughts are unbearable if you're if you let them go right which is i'm gonna get to the airport i'm gonna miss my flight then i'm gonna have to wait for another flight and i'm probably gonna miss that too or they're not gonna be a good seat or whatever and then i'm gonna not get to where i'm going and maybe the whole trip's gonna do that and and so what is what do you say to the person who says okay shireen i understand that those thoughts which are all future are not happening to me now and i can just sit here right now in this car and frankly i could turn on music and enjoy the music for the moment but that doesn't change the fact that that's going to happen it doesn't change the fact that in an hour i am going to get to the airport i am going to have missed my flight what do you say to the person when they they acknowledge that i could probably take myself down from 100 to 50 by being present in the moment but will i get back to 100 when i get to the airport when i realize that i now have to deal with this mess possibly but that's a new moment now now you're in a new moment and a new situation so part of it depends on well what's your what's your goal uh so when you're experiencing distress in that moment of being stuck in traffic and not having any control about that what's your goal if it's to get to the airport in two minutes sorry that's not a realistic goal we're gonna have to let that one go if it's to problem solve what will happen when you get to the airport is there something that you can do while you're in the car you know possibly but if your goal is to how do i make this moment more bearable because i can't undo anything then i think we have some other options available to us which could be distracting you know doing something like music or or some other forms of distraction that you could safely do in the context of your car okay so now let's look at kind of the other end of the spectrum where i think it becomes even harder to do this so i'll think of two examples i think of an individual who receives a terminal diagnosis so they're diagnosed with a cancer for example that um and let's let's make this even more tragic right i think anybody dying of cancer is tragic but now it's someone your age or my age who's you know dying decades too soon um but they're basically told and and it's accurate that look in six months you're not going to be alive um so in that sense they're they're you know they're they're mourning the loss of their life and who they're going to be away from and then there's another example which is very fresh in my mind right now because um you know my very close friend and my wife's uh daughter drowned um a year ago and and because we're coming up to the one year anniversary of that it's it's all you know she's reliving a lot of this so you know it's hard for me to imagine what she's going through and what her husband is going through but they can't there's no there's there's nothing that will undo that there so so maybe use those two examples as two of the the most difficult examples of how can radical acceptance allow the hey this this person who's gonna die far too soon to come to grips with that and maybe have a chance at having the best six months that they can have versus not you know you know and then perhaps even more tragically the you know a parent losing a child is you would sort of hold that up as about as tragic as anything can go where nothing is ever going to bring that child back um and yes cognitively you can say look you still have other children and you have to be a great parent for them you can't allow yourself to you know you can go through all of that stuff but like i don't know how i would cope with that i don't think i could i'm not sure so yeah now let's go from the sort of banal of traffic to the the really heavy stuff of life yeah easy right so uh i mean one i've thought about both of these things um a lot or both of these circumstances a lot and i think one of the misunderstandings about acceptance somehow this idea that if you accept something you don't experience pain and so i want to differentiate that uh life is full of pain no matter how zen and mindful you are you're going to experience uh pain and a lot of pain and we're not trying to eradicate pain because actually without pain um and i don't mean you know physical pain i mean emotional pain but it could be both but without that we would have other problems right if we did not experience um pain as you hear about your friend's daughter that would be a problem for you in a different way so we need to understand that that pain is going to be a part of our lives and actually we cause a lot of problems for ourselves when we try to escape the experience of pain so that's one thing about um reality radical acceptance that i want to talk about but the other is when when you ask questions like that like how can we ask somebody to radically accept this i would answer in part by saying what's the alternative the alternative is refusing to accept how do how does that work how how do you do that um how and how long can you sustain that for so i would actually argue that the refusal to accept or the putting your head in the sand or the denying reality actually ends up taking a lot more mental resource and ultimately causing more problems for you in the long run and that said from a dbt perspective when we when we talk about practicing the skill of radical acceptance we have another expression called turning the mind which is referring to the fact that practicing radical acceptance involves a very active process of continuously turning your mind towards acceptance the the metaphor is that you're at a fork in the road and one road is acceptance and another road is is refusal to accept you're gonna come across the fork in the road possibly multiple times a minute and what does it look like for you to say i'm going to actively and willingly choose the road of radical acceptance how can i turn my mind my body my soul towards acceptance and for me a lot of it is actually asking myself that question of what's the alternative what other choices do i have and recognizing that more suffering comes from refusing to accept um more often the fact that it's referred to as radical acceptance versus acceptance i i think kind of highlights that that it it's not easy it's not it's not a decision it's not like you would sit down with my wife's friend have this discussion once say what's the alternative i know this is awful but in the long run this is going to produce more happiness for you and your family and for her to say yep i think that's right thanks like it's uh no it's not it's to your point every minute of every day for god knows how many months and years you're confronted with that and if i speak for myself there's a lot of uh what's the what's the term uh uh backsliding right there's a lot of no i don't want to accept this today like i'm not i don't accept this this is i'm angry about this i want to pout and have a little pity party about this um and then maybe i experienced that and i realized that wasn't very productive because now i feel actually worse and so um you know one of the things about dbt that i so i you know we were introduced through andy white which is who i work with and i just i just think the world of andy one of the things about dbt that for me makes it a wonderful system is that you do work like you you have you you write you do you have homework you you you have to talk you know write out your emotions and your decisions and the the trees like how you know if you feel this do you do this and i don't know i how deliberate was that in in marsha's mind as a system i've never done cbt so i don't know if cbt has a similar workbook and she's just modifying it um is that is that something that's been modified from other systems certainly cbt is associated with doing homework doing work in between sessions um uh more standard cognitive therapy is associated with doing worksheets about your thoughts what thoughts you have what the evidence for your thoughts are that sort of thing and so i think doing work doing worksheets not shying away from the term homework as part of the treatment is very consistent with the cbt model what i will say is um you just reminded me about this based on something you said is that one of the assumptions about borderline personality disorder from the dbt lens is that this is uh we use a skills deficit model which is to say that we believe that people who end up with the constellation of problems associated with borderline personality disorder have an absence of certain skills and skillful behavior in their lives and that absence could be a result of never having been taught it in the first place or having had effective behaviors been punished out of them by their environment this is the environmental piece that we're talking about but they they don't have um we all you know have certain deficits in in some air in some skillful areas and so the work another one i would just add to that it's so so yeah the skills have never been modeled for you you've done them correctly and been punished for them i think a bigger one might be you've done them incorrectly and never been corrected yeah that's a good one too yeah absolutely so you built all the muscle memory doing it wrong your whole life and you didn't have parents there to sort of say hey that's not how you do it just do it this way yeah and it's a lot harder to unlearn a behavior than it is to learn a new behavior and that we know that as a phenomenon so so marcia developed this you know this workbook what we refer to as the skills training manual that's part of of the treatment of dbt and perhaps what dbt is probably most known for more broadly speaking are the skills that are part of it but that these um skills deficits are thought to exist in in four different domains or five different domains actually uh mindfulness um so when we say someone has a deficit in mindfulness it's not that we're referring to anybody who doesn't practice zen as having a mindfulness deficit but it's a deficit in excuse me a deficit in the capacity to be aware of the present moment basically another domain in which people have deficits is interpersonal effectiveness as i go through this you'll see everybody has deficits in in all of these areas at different times and i think again that's that's part of the beauty of dbt is that it can help so many people so interpersonal effectiveness which could mean conflict with others but also could mean deficits in in knowing how to ask for something effectively how to say no effectively emotion regulation deficits is the third domain so uh deficits in knowing how to label your emotions what to do with emotions when you have them how to prevent having intense and extreme emotions how to change emotions can't remember if i said that uh and then a fourth domain is is deficits in distress tolerance how do you tolerate really stressful and distressing situations without doing anything that to make the situation worse and then the fifth area um that is not talked about as much so i can certainly talk about it if that'd be helpful is this idea of self-management deficits and self-management which has to do with um being able to do things you don't want to do you know broadly speaking you know how some people can get up every morning at six o'clock and go exercise and eat a healthy breakfast uh and you know go to work while other people snooze their alarm eight to 12 times you know haphazardly eat breakfast sometimes get to work late you know those are sorts of things that we might say fall into this kind of self-management domain and so dbt is designed as a treatment package to teach people the skills to overcome deficits in these different domains so i actually wasn't aware of the fifth i was really only aware of the four is that fifth one um is it kind of a more recent addition so it actually is in the original treatment manual in the 1993 um text that she put out but her thinking was i don't need to create a whole other skills module for self-management because dbt therapists are going to infuse this throughout their entire treatment and i think this might have been at the time a little bit of a missed opportunity because i don't think she realized that actually a lot of clinicians don't know how to do that um very well marcia was thinking that actually this is where behaviorism comes in it's teaching people principles of of behaviorism so you don't see it in the original skills manual and you don't necessarily see it in the new skills manual or what i refer to as the new skills manual unless you look because where you would see it now is in the set of skills that are referred to as the walking the middle path skills which are which actually came out of um the first adaptation of dbt for adolescents and their families um and jill rathis and alec miller who along with marsha created the adolescent version of dbt took a lot of these principles of the self-management skills and created this fifth module of dbt skills called walking the middle path in which they teach adolescents and their caregivers their parents these skills about how to how to manage your behaviors how to learn behaviors um and to be more effective more broadly you know just kind of going back to the origin of dbt around basically um a modified tool to help some of the people who are suffering the absolute most right if you think somewhere in the back of marsha's mind it probably wasn't just how do i make cbt better to handle the most recalcitrant depression suicidal patients perhaps on some level it was also bpd right which we didn't we kind of glossed over this but i'm guessing that cbt has historically not been very successful for borderline personality disorder is that a fair statement well i would say at the time that marcia was was doing this treatment development we didn't know um and i think the the general thought and there actually there have been more studies that have looked at whether the presence of borderline personality disorder interfered with outcomes for standard cbt and there's kind of mixed data on that in that some studies show that the presence of bpd did lead to worse outcomes in in some studies but what i was going to say is that marcia didn't know one the reason that she gives for her pivot to borderline personality disorder as a population of interest is that when she was first seeking research dollars research grants to study the development of dbt and the you know to start to do randomized clinical trials of the of dbt rather back in those days you could only get research grants from nih if you identified a disorder of interest the way she tells it as oversimplified is that you know she was interested in suicide and suicidal behaviors and at the time she thought her choices based on that behavior was either depression or bpd and she said at the time she didn't want to do depression because there were already so many um smart people doing depression research she wanted to do go into an area where there weren't already a lot of people doing research in this area and that's why she chose bpd again this is the story but of course i think there's more to it than that because i think the you know her own experiences uh would lead one to assume that she also had specific interest in the emotion dysregulation piece that goes along with bpd and doesn't necessarily go along with with more standard depression yeah i mean so what would you say i know what i would say but what would you say to somebody who doesn't have bpd doesn't it's not depressed who says you know peter shireen this is all very interesting but what would there ever be any benefit in me doing dbt given that this program was really built around people with real pathology of which i have none if you i went through the dsm 5 last week nothing in there i don't meet the criteria for anything fully um would i have any would there be any value to me in in this type of practice i think that's part of what's so fascinating about this treatment because you're exactly right this was the treatment that was developed for what could have been termed the worst of the worst at the at the time and it's a treatment that is actually for all of us i have yet to meet a person who could not benefit from at least learning some of the skills nor have i met a person who i've yet to meet a person who hasn't identified the skills as being something that could be relevant for them now whether they're always willing to use them or apply them or want to do them that's a different issue but when i talk about here's what the skills are for i get universal agreement that those skills could be useful to learn yeah the way i kind of describe it i you don't know this about me but i love cars and race cars and all sorts of things like that and a lot of people say like i don't really understand how there's any value in you know a company like mercedes or you know any of these companies participating in you know building race cars you know it's such an expensive proposition it seems so gratuitous but the trickle-down effect for what the impact of that is on street cars is remarkable in terms of fuel efficiency power safety all of these things you know it's true if you want to build a formula one car it's you know it's basically a 400 million a year operation to build and operate those things but those things are functioning at the absolute limit and if you you know where every gram matters and the stakes are so high and if you take everything that you learn there and bring it down to the rest of us who aren't driving formula one cars the benefit is actually enormous and i think of it as sort of similar right which is this is a system that was conceived and validated on a sample set of people with real difficulties in regulating their emotions and you know when i go through the list of the dbt you know skills pillars it's like i mean check check check check check right i mean i can i might not meet the diagnostic criteria for something in the dsm-5 but i mean i have enormous problems with all of these things i have staggering deficits of skills i mean one of the first exercises that really illustrated that was something as simple as identification of emotion you know it was any emotion i wouldn't say that that's simple necessarily yeah yeah but but it was like i couldn't really identify an emotion that wasn't anger it was very difficult to go beyond anger to helplessness sadness hurt fear all of these other things so that i mean i don't know andy and i must have spent three months with my homework just being okay you're going to get angry 16 times a day 16 times a day pull out this sheet and go through and figure out what else is going on you know that's that sounds maybe simple but that's learning a new language as well what what made you want to do that why not just stick with your experience of anger yeah i mean look it's it's exactly what you said earlier it's like what's the alternative well the alternative is you're really you know alienating a lot of people um and i think watching my kids get older and realizing i don't want them to see me always angry i mean you know i think i was just angry 24 7. i don't think i really experienced anything that wasn't anger um so yeah i think it was just uh it was it was sort of just saying like i have to sort of break this cycle because it's you know my kids will if every time i get cut off on the road i'm screaming so much at the person who cut me off that you can see the droplets of my spit on the windshield even if i'm not yelling at them it's not like i was actually yelling at my kids but it doesn't matter i don't you know as i've learned since i don't think kids can appreciate the difference a five-year-old doesn't understand that just because daddy is yelling at the guy that cut him off he's not mad at me so i think once i came to realize that i realized no this i don't want to do this yeah i think these skills are for i just totally agree i mean i've been so i don't actually have my own experiences with borderline personality disorder or psychopathology in that way and i learned dbt as a grad student in you know my early 20s and it's been a long time now or that i've been using and applying dbt and i will still go in my head like when i have a difficult interpersonal situation happening where i will walk through the steps in my mind of the the dear man skill of how to ask for something and be effective let's go through dear man in a moment finish your story but i would love to go well i was just going to say like it's been 25 years and i'll still be writing an email and then i'll say wait pause edit am i following the dear structure what what can i take out what am i adding on what judgments are in here so i feel like i you know i've been a pretty skillful person for most of my life and i still need to i still benefit from actively thinking about uh using these skills in my daily life so i mean i'm still so early in my journey i would say i'm you know if if if 10 out of 10 is having all the skills and always employing them one out of ten is not even knowing what a skill is you know i'm in the sort of three to four out of ten range which is i know them and i don't know maybe half the time i reach for them correctly um but let's talk about dear man um because everything in dbt is really built around being highly accessible it's not it's not really at least to me it doesn't come across as having errors right like this is you know it's it's funny acronyms it's like little diagrams it's there's nobody that can't do this right so um [Music] tell everybody what dear man is and what the acronym is is really used to walk you through as a thought process right i think sometimes people actually have a negative reaction to all the acronyms in in dbt and i think that's a fair criticism but acronyms are you know meant as mnemonics to help us remember um maybe because i went to medical school we just you do so much through that yeah yeah yeah though i will say i was training dbt somewhere where was i i think it was iceland was it iceland where they don't do acronyms um like it's just not part of their language uh to use acronyms and so that is an added difficulty but in in the us and canada and we can talk about these acronyms so dear man is a skill that's in the interpersonal effectiveness module so this these are the skills that are designed to help you be more effective with other people in your life and dear man is specifically the skill to uh on how to ask for something in a way that gets another person to give it to you or how to say no to something in a way that gets the other person to accept your no or increases the likelihood i should say because nothing is going to be 100 effective so dear man walks you through these seven kind of sub skills to help you do that so it stands for describe express assert reinforce that's the the dear part that's that's basically what you say um or write to ask for something and then the man stands for mindful appear confident and negotiate or be willing to negotiate so that when you're in a situation so i don't know do you have a situation that is coming up for you where you need to ask for something or say no to something yeah i do actually um i don't think i can talk about it publicly unfortunately it's such a very good one but i probably can't talk about it publicly let me think of one where i could um um without embarrassing someone uh okay this is going to embarrass the hell out of her but let's try it my daughter wants to get a third earring so she's got two piercings in her ears and she really wants to now get a third and i'm not sure maybe this isn't a great example but i'm hoping to talk her out of it for a little longer how's that i i'm like why don't you wait till you're a little bit older i just have this fear that she's going to you know damage her ears and have so many things hanging that will stretch her earlobes out and she'll be 50 years old like me one day and regret it potentially a totally irrational fear but that's the fear i have so the ask that you want to say is can will you postpone this decision for a while or will you take this off the table for a period of time right and the wreath because someone listening to this might say what kind of lousy parent are you just assert it but um but but her mom is not opposed to it her mom's like i think it's reasonable for her to get it so now it's become kind of more of a negotiation and how old is she uh she's 13. yeah so i would say the more you tell somebody a 13 year old not to do something that's pretty much the recipe for her going out and doing it so uh so if you were to practice the dear man the first step would be to describe the situation without adding on any interpretations or judgments so if i were your daughter you would say to me um olivia i understand that you want to now get a third earring great so often this means exactly what you did which is to keep it short because sometimes we have a tendency to go on and on and on about all of our reasons for something but actually the more we do that the more we lose the other person's interest and then express would be to express your feelings about it i have some fear about you getting a third earring because i worry that it would damage your ears and this would be something that would bother you many years from now right so you know we could work on on simplifying or shortening or saying i i fear i have fears that you would regret this if you did it whatever it might be to get the express but that was also really nice because you didn't add on judgments you didn't say you shouldn't do this right these are all just describe the facts and then express your feelings about it now assert is where you ask for that's the a where you ask for directly what it is that you want olivia would you be fine if we could postpone this decision until you're older maybe even out of high school so you may think about prior to doing it what is it specifically that you're asking for so if you want to start out by asking i'd like you know would you be willing to postpone this decision until after high school might be a more direct assert but it could be there's other factors that might contribute to you asking it more tentatively or more firmly but making a direct ask now what we often say about this you didn't illustrate this but what we often say about this a part the assert is that a lot of the time we don't actually assert we just want somebody else to read our minds or do what we want and i think this is especially a problem for uh not to over generalize but i think women have more trouble with this on average than men loads of reasons for that but actually asking directly for what it is that you want is is really challenging for people and so what instead you would see people doing is just doing the describe and express and then expecting the other person to just know what it is they want and do it so we're trying to get people to to learn how to be more comfortable with asking and stating directly what it is that you're that you want and then the r is stands for reinforce uh which is to say you want to say explicitly what's what's in it for the other person what reward could come their way by by giving in to your request or giving you what you want which in a second we can talk about whether or not this is manipulation but in the moment uh in your dialogue with olivia what's in a what's something that you could imagine uh reinforcing so here's where i could go into many directions right one direction is you know you play volleyball you're really good at volleyball you're you're playing year round now and the more jewelry you have on the greater your risk of injury you get hit in the head with a ball that's one more thing that could hurt this is just one less thing to worry about right that would be one sort of very narrow niche approach probably my preferred way would be something like optionality is a great thing and by not doing it now it doesn't mean that you can't do it tomorrow you always have that option but you can't undo it once you have it now she'll argue yes you can you can just take it out so i don't know maybe she's right but um that's probably those would be the things i would reinforce which is i'm not saying no i'm just saying not now and that really isn't taking anything away it's just potentially delaying something yeah so what i would say is that i agree with you about all of those points what you're doing is you're providing more evidence in favor of what it is that you're asking for but if i were to think about about uh reinforcing in the sense of what reward could she expect if she were to say yes dad i won't get a another piercing so is this something like where i could literally just say and if you don't do this like i give you know is it literally like you're bribing your kid is that potentially what's in there well it could be uh but i wouldn't necessarily i mean it would be bribery but bribery is what we do all the time right if you mean would it be something like you know and if you don't do this i mean we could go shopping in those new converse shoes you love let's get those instead it could be okay yeah i never thought of it that way right i've always thought of it in more sort of theoretical reinforcement which i think um can work sometimes with some people but i think uh more often than not it needs to be a tangible connection to to this now what we often say is a good good fallback you know to asking somebody for something um at work or interpersonally is to say if you do this i would really appreciate it right my appreciation of you and your behavior is a reinforcer right you might feel good by the fact that i appreciate it when i see something like what you're describing your daughter wants her dad's appreciation of not high on the list of things exactly right so you have to think about the person that you're asking and what is most likely to work now and and you also have to think about it to a certain extent how important is it for you to get this thing that you're asking for and if it's really important for you to get it then you might say oh i don't like you know buying her sneakers instead but if that's what worked then we would say you know be effective like in this situation if this was something that was really important to you well and i think it illustrates this i'm glad we did this example which is kind of like i thought of it as well sort of glib but it illustrates another point which is um there's sort of there's a meta thing here which is i'm teaching her by my behavior and my interaction what is a more emotionally regulated way to handle this because i think if the old version of me would have just said no like i'm the parent you're doing what i say like this is non-negotiable and you know if i was a kid and argued this i would have got the back of the hand to my face so just be lucky you're not getting that for even pushing and provoking this discussion you know i mean like so so that would have been the old way to have dealt with this and and so i get to at least think she would have run out and gotten the earring and just right right so now instead we get to model something better and i i think that that's the other i assume that that also factors into the dbt for adolescents which i actually haven't maybe it's time that i sort of look at that as well but i haven't really spent any time looking at that work but i would imagine that it's as much about helping the kids as showing the kids how the parents can change as well well what what is an amazing adaptation for dbt so in standard dbt for adults in uh what we do we haven't really explained like what the therapy looks like but in general what would happen if somebody were receiving dbt treatment is that they would be coming to a skills training group once a week or receiving skills training individually where they meet with a therapist who teaches them these specific skills they practice that they come back report on their practice and get feedback and coaching et cetera in skills training group you might have a number of adults all together and you teach them all together and you assign homework and you all talk about the practice and use of skills what was an amazing i mean i just think it's so brilliant adaptation for dbt for adolescents is that in your skills group you have now multi they're called multi-family skills groups where you have the adolescence in the skills groups but you also have the adolescent adolescents parents or caretakers in the skills group at the same time and everybody is learning the skills altogether and the way these groups are designed it's not oh we're all learning these skills so that you all can you know help your adolescent apply them of course that's part of it but we're framing the groups as saying we're teaching everybody the skills because the parents need the skills as much as the adolescents need the skills and therefore the parents have been caregivers have to practice the skills the on themselves not just for their adolescents i mean do you do do you find it's do you find it's harder for the parents because you know you said something earlier which i completely agree with it would almost be easier to come to dbt with no skills positive or negative and then just learn the positive skills it's harder to come in when you have decades of reinforced negative skills anti-skills and you have to unlearn anti-skills and then build positive skills so do you see that it's easier for the kids sometimes to pick this up than their parents i think there's um sometimes easier to pick up but there's different levels of willingness and willfulness yeah sure so with adolescence a lot of the times adolescents are not necessarily there by choice i'm guessing sometimes yes so a lot of the times it's their parents or their schools that say they have to do this and so there's always a question of how much they're there because they um want to be there adolescent i mean of course with adults in certain contexts and situations they don't want their to be their easy uh either but there's generally more willingness um let's talk about the structure of the therapy i've jumped around a lot because there's just so many interesting frameworks and i want to make sure we get to them but um let's assume that you know a person comes to you now um and they're there by their own choice this is an adult and they don't meet the criteria for any of the dsm-5 so this is just someone who's having difficulty interpersonally um you know one of the things that i think i sort of realized was so much dysregulation stems from interpersonal interactions gone bad with your spouse with your child with your coworker with the person who cuts you off on the street i mean it's generally an interpersonal interaction that doesn't meet your expectations whether those are reasonable or not reasonable that then leads to sort of an emotional regulation or dysregulation thoughts that then feed into those emotional dysregulations and then you create this awful feed-forward loop that can lead to bad behaviors i mean that is that sort of a safe way to talk about it from interpersonal to thoughts uh emotion emotions thoughts feeding off each other and then behaviors i mean that's kind of like the pathway of how this all seems to go wrong for people and i mean there are some people out there who just i seem who seem just wonderful and they don't seem to suffer from these issues but but most people if we're being really honest with ourselves even if you're not as extreme as as me i think most people realize that this isn't always going well especially as we're under more external stress you know there are i i love the idea of distress tolerance um and i think that's just one of the most interesting concepts is a window and that's the sort of image that i have of it right so i mean this entire year my distress tolerance window is about this thick and it's all my own fault i've put way too many things on my plate and so there's no buffer there's no margin for error one thing even before this podcast was recorded i was getting upset about some stupid video i had to record that i was like give it i had to record it twice it was supposed to be two minutes the first time i did it it took two minutes and 20 seconds like something so dumb that shouldn't even bother me bothered me because i'm out of time so so something like external factors will change your distressed tolerance window and and for me it's always being too close to the top where it's getting upset but for some people it's being too close to the bottom and it's getting you know sort of dysthymic or depressive uh versus getting irritable and during good times like people imagine being on vacation where for two weeks like you don't have to worry about email nothing is going on you know nothing really seems to bother you doesn't you go to a restaurant and they forgot your reservation you're like yeah no problem we'll go to the next one like it just you know i think people can resonate with this idea so one of the skills is how do you make that distress tolerance window higher how do you make it wider there's nobody that's not going to benefit from this so it's a long rambling question but really where i'm going is you get somebody that comes in where do you start well i will say that one of the when when you just said that what i was reminded of is what is learning what makes us more vulnerable to negative emotions or stress or distress and that is another key skill in dbt is to identify and understand what our vulnerability factors are and then to address because sometimes we could actually solve our you know uh target or treat our vulnerability factors and our lives just go much more smoothly you know when we sleep uh decently you know when we remove some things from our list so that we're not so stressed all the time like that could actually solve a number of problems but where i start with by the way i want to that's i'm glad you brought that up because i i should have mentioned that's actually one of the first things andy asks me every single i i work with andy once a week so we every you know i've been working with him for two years now it's always once a week um but that's one of the first questions he always asks which is tell me what's going on physically right so are you in pain are you sleeping uh what are the other vulnerabilities and i think out of the gate he's trying to gauge what state i'm in as a function of how many things are pressing me and what uh and i mean i can't speak for what andy's doing but uh and how um in those moments how able are you to receive info like if you're at you know a 90 on a scale of 0 to 100 you're not taking in a lot you're not learning a lot right so we if you're at that level then we need to figure out how do we get you regulated enough so that you could learn uh learn to do something differently and i think that that's great that he asked those questions i think for myself when i'm in physical pain i i just can't do much of anything and it makes me admire yeah yeah and or sleep deprived as you said i think i think uh he he's he's had me pay much more attention to those things like if you haven't slept well in two nights you can't and you shouldn't assume that you're at your best in terms of your ability to receive both information and tolerate things physical pain is a very interesting one i agree with you completely i'd love for you to share an example of your own life i have so many of where i've been in pain and it's made me more irritable what what what have you noticed and what do you do about it specifically well what i was gonna i just admire people so much who have chronic pain conditions and and function in their lives because i have been fortunate to not i mean i've had pain um but to not have a chronic pain condition uh because i think that would be a challenge for me to learn how to navigate that but i do think that when i'm experiencing pain and whether it's you know a transient headache that i know will pass or um i hurt my back you know exercising and now i feel it you know every which way i i personally recognize that as a huge vulnerability factor for me because it makes me more irritable um in general and makes me much more likely to to snap at people um or to have less patience for things so for me what that means is recognizing kind of similar to what you said like okay this is going on for me right now i have to accept this is going on for me right now because i can't just will away physical pain as much as i want to and know that this is a vulnerable time for me so given that it's a vulnerability vulnerable time for me is there a way that i can reduce demands on myself in other ways or is there a way that i can treat myself kindly in other ways to kind of offset the the pain that i'm experiencing and sometimes it's for me it's also um learning to be more explicit and vocal as it relates to kind of this interpersonal effectiveness uh because when we experience pain it's often entirely um experienced within our bodies other people may not uh even know that this is happening for us so learning to say out loud and no granted it helps as your kids get older you can say things when they're younger you can't say as easily mommy has a headache so you know but they get older and you could say um i'm really suffering right now from this headache so i need to have a little bit of space um you know from this conversation or this situation so learning to recognize this as a vulnerability factor and then figuring out how can i act more skillfully within this context um to prevent the lashing out to prevent irritability because i don't know if this is your experience peter but mine is that whenever i do act out of anger i almost always regret it and almost always feel worse about myself um afterwards and so it's almost a selfish process it's it's to help the other person by saying i'm not gonna get irritable with my kids it's to protect them but it's also to help me not feel so bad afterwards because my kids will recover i'll recover but i don't like how it makes me feel yeah the the cycle of anger and shame and isolation is is a is a pretty frequent i know the path well um you know before we leave the pain thing one thing i've observed in myself is not all pain is created equal and expected pain seems to be far less destabilizing to me than unexpected pain so i had shoulder surgery recently um i don't know why i hadn't been told how much it would hurt but and i so i didn't really want to take any of the narcotics and things like that i mean for a week it was i mean for two days the pain was so bad i couldn't sleep i mean literally i was just sitting up in a chair not sleeping for two nights but even for that week the pain was excruciating interestingly it didn't uh negatively impact me in terms of interactions like it didn't i would have guessed knowing what i know about how much pain can destabilize distress tolerance um capacity i would have thought well that would have thrown me over the edge but it didn't because it was like look i had six trokars in my shoulder i just had an enormous operation this is kind of what it's going to feel like whereas i've had headaches that have lasted for three days at a time due to you know some awful tension and no amount of tylenol can make it go away and it ostensibly it's not as bad as my shoulder was hurting but one i don't expect it i don't know why i have it it i find that far more destabilizing to me from an emotional regulation standpoint i don't know if you've ever observed that and by the way i think people with chronic pain that must be the most frustrating and difficult thing because a lot of those patients are told by physicians like either a there's nothing we can do or b this is in your head and really you should just kind of ignore this i 100 percent agree with you personally and professionally what i noticed and what you said is that you actually engage in a lot of self-validation with regard to the shoulder surgery basically saying of course i feel this way it's okay to feel this way and i think with the other pain that we experience sometimes we might not realize that we're doing this so explicitly but we're actually invalidating such a great point we're saying why am i feeling this way what's wrong with me how could this be happening right and so we're rejecting it and and i have my own personal example i'm i'm tapering off a medication right now and i didn't realize when i was prescribed this medication how difficult it it's known to be a medication that's difficult to get off and had i known that um it was sort of a moment of weakness that i was prescribed this i decided to take it had i known how horrible it would feel to go off it i never would have gone on it um but now i'm i'm trying to wean myself off of it i'm i'm really going kind of nuts with how much i'm like micro dosing myself on this medication because i start to feel this this withdrawal symptom and i'm realizing exactly to this point that you made is that part of the suffering that i'm experiencing about this is my thoughts like oh what if this goes on forever what if this doesn't end and and even when i realize okay it's not gonna last forever the subsequent thought is but can i tolerate this for two weeks you know why can't it just go away and so this is the way in which we do have some control over the suffering that we experience because we're adding on all of these thoughts and so one of the one of the mindfulness tricks that i really um love when i hear it i think i heard it as it relates to like learning to be mindful and accepting of your emotions is just to say to yourself it's okay to feel this and it seems so simple but just say those words it's okay to feel this no matter what the this is is can be a really powerful experience and i think even with the pain we could say it's okay to feel this and just notice what effect that has on us so going back to kind of the beginning of the interaction with the clinician and the patient you start with this idea of what are the vulnerabilities so once you sort of establish that and i suspect a lot of that is you'll see it quicker than the patient will like a lot of times people probably don't appreciate what the vulnerabilities are until they're kind of pointed out which is no like these are again it's a form of validation these are really clear things that are going to make it more challenging for you to be understanding of others to be understanding of yourself to regulate your emotion to control your thoughts and ultimately to control your behaviors so once you establish that i imagine it's somewhat liberating for people it's it's kind of a nice first way to have you validate things for them is that usually received that way uh so i think for a lot of people understanding the vulnerability factors and and determining ways to reduce their vulnerability is really critical and you ask me like what i would typically do with somebody who first came in and i think that is something i mean i'm used to working uh only with people who meet criteria for bpd and are on usually on that more severe end of the continuum um so i don't have a lot of people i don't have experience with you know people that um are not as extreme usually so i think that for a lot of people learning about vulnerability factors is really important but i put vulnerability factors in the context of something that we do in dbt called a chain analysis which is a way of assessing um problem behaviors that people have that they want to change as a way of assessing it in order to figure out how to change it um going forward so vulnerability factors is an element of that chain analysis so say for example you know you were in treatment with me and one of the things we were working on is is this target behavior of you um uh exploding in anger at you know various um points we would identify what a recent occasion in which that happened and then we would do an assessment of what were all the factors events thoughts behaviors that led up to that behavior and then what were the consequences of that behavior that would be the chain that we assess as a way of identifying okay well what can we modify in this chain going forward to make it less likely that that problem behavior is going to show up again and i think what we've been talking about is addressing what happens actually very early on in the chain that vulnerability factor and for some people and in some situations working on the vulnerability factor changes everything that follows but there's other events and circumstances where uh it's not about the vulnerability factor or the vulnerability factor is just one element but something happens in the environment a prompting event we would call it perhaps that sets off the chain and it doesn't matter whether you got sleep or not the night before because no matter what that whenever that prompting event happens you're going to explode in anger right so we want to work on vulnerability factors but we also want to identify well what are some other critical elements along the path towards the problem behavior that we can address and and behaviorally manipulate yeah i mean when you state it that way it's really obvious because you know even using myself as an example which is probably a more extreme example nothing ever occurs in isolation like i've yet to come up with one example in my life where i can say yeah i flew off the handle and it was only because of what was happening in that moment i mean it's just not the case it's if i flew off the handle this is a situation where i would have barely got upset a day ago or a week from now it was the literally the six things that had happened and maybe yeah maybe i didn't have a great sleep that's not what caused it of course but that made me more susceptible and maybe this other thing happened and i didn't deal with it you know i didn't confront the person who said such a thing that upset me and i just sort of buried it and went on and maybe i you know read something on social media and i didn't even acknowledge that that was very upsetting to me somebody attacked me and i sort of ignored it and then i find myself in this situation and um i i liken it to sort of the the challenger blowing up you remember when the space shuttle challenger blew up this is you know got almost 40 years ago now um it's so interesting and i'm an engineer by training so i i really have a keen interest in in kind of the ins and outs of that type of scenario and what you realize is like there was nothing sudden about that horrible tragedy nothing about that was remotely sudden and unexpected when you actually peel back the layers of the onion and go through the entire chain analysis for not just the challenger but all the previous space shuttles and you realize how inevitable this was and on that day this was almost a foregone conclusion um and yet at the surface it just you know again now imagine watching that as a spectator oh my gosh how could that happen well it it ties into the you would get an a on your dbt test because it ties into the dialectical philosophy of everything is caused right and everything has multiple causes and that is very hard to accept sometimes and it's also very hard to experience especially in our dominant culture that wants us to believe that there are simple answers uh and there's one person to blame or one root cause that's that's what the dominant culture is trying to tell us about everything and anything because that's simple and it's more complex than that that there's always multiple determinants of anything and that we could dissect any behavior any problem and see the thousands or millions of causes that led up to that behavior i have one of the pages in front of me that i've copied from my skills book that has so many of my notes in it um and it you probably remember the page it's sort of what makes it hard to regulate your emotions and i've all this is probably one of the 10 you know this is a 350 page 400 page workbook but this would be there's probably 30 or 40 pages that i have stickies in and this would be one of the 10 most important and it's just this great reminder so just for the person listening to this so what makes it hard to regulate your emotions biology let's just acknowledge there are biological differences between us our brains are different um i won't go into some of the details there but but you know anybody who has many kids more than one will recognize that they are simply different even if they're raised identically one that we already talked about lack of skill right so lack of skill because skills were not taught because good skills were pushed away or because bad skills were reinforced i think this comes from it which is reinforcement of emotional behavior so kind of going back to childhood this one's very interesting right moodiness right your your mood in the moment will alter your ability to regulate emotion um this one i can relate to a ton which is emotional overload so the more pressure you have on you whether self-imposed or otherwise the more difficult it is and then one that i love which is emotional myths so mistaken beliefs about these things and i just may i have my own notes here one of them says when i can't regulate it is almost always the case that at least one and typically three of these are happening um so it's very interesting you know again three of these really peg to childhood right the biology the reinforcement of emotional behavior plus or minus skill and the emotional myths yes i definitely think that they um a lot of them are long-standing patterns and some of them are are current and also contextual so for example there might be a person in your life just one of many that actually when you um uh display anger gives in to everything you're asking right and that this could be totally outside of your awareness but that means that you're more likely to have that anger response with that person in that context uh in the future i had a while you know before my husband uh ex-boyfriend at one point who um when we would argue if i started to cry he would immediately back down and this was outside of my awareness that this was happening but i realized over time i found myself crying a lot more than i ever had before um and crying is i'm not saying crying is good or bad but i just noticed that that was what was happening because in that context with that person that behavior was was being reinforced and i feel like this could happen so subtly and it's so contextual that how we and why we're sometimes different with different people um is because of that this is often at least as it relates to bpd is is like pathologized oh if a person if you're different with different people there's something wrong with you you have no core sense of identity or something but i would say it's actually pretty normal we're all different with different people because the context you know often call for that and it's adaptive to be that way so is it essential for everybody who's practicing dbt to also be practicing mindfulness meditation given the importance of that first step which is recognizing the thought it is uh well we might have to disentangle what we mean by mindfulness meditation because i would say mindfulness as a skill is central to everything yeah sorry let me rephrase the question given the importance of mindfulness as a central tenet to this entire practice is it also suggested that people use a form of meditation that practices that skill you know you know typically focusing on something like the breath or an object and you know bringing their attention back to that every time it wanders as kind of one form yeah we have actually debated this uh within dbt and i remember actually there was a while that marcia was when i was a student of hers and therefore seeing her every day when uh she was on this this kick the last of lack of a better word saying that uh we need to get all the therapists to practice seated meditation like you're describing for at least 20 minutes every day and actually there's a a form of cognitive behavioral therapy uh called mindfulness-based stress reduction mbsr you may have heard of it for depression in which they they teach people who are in the treatment to work up to that seated meditation um and they also require that therapists who do mbsr also practice it that way and so marcia was thinking do i need to require this i remember even way back when um arguing against it at the time because i thought that's that's not actually practical for everybody always i think about a working mom who a single mom with three kids and to say you need to find 20 minutes a day to do seated meditation is is um impractical um there have been many times in my life where that was impractical as well so uh she and part of this was to try to figure out like how do we define a dbt therapist how do we know when somebody is doing dbt um so we she never ended up requiring or saying that therapists have to do this but what she would say is that therapists who practice dbt have to have a mindfulness practice but that practice could be anything um under the umbrella of mindfulness so you do yoga that's uh could be your mindfulness practice or you do mind you know you do mindful walking or you do mindful participating in various things and i would say that that is something when it comes to clients who are in dbt we want them to strengthen their mindfulness muscle absolutely and if i have clients who are interested in learning to do seated meditation that's amazing and i would support that entirely i think for a lot of the clients that we work with at my clinic that would be too big a jump and why marcia doesn't doesn't say that clients need to do this because lots for a lot of people who are in dbt who might be at that more severe end of the continuum just sitting with themself and their thoughts and their minds without doing anything to change it for a minute could be excruciating um so we're trying to build that that tolerance of course but the mindfulness skills in dbt are much more concrete and practical and designed to be used in any moment rather than um designed to facilitate a more formal practice you know obviously we can't cover dbt in any comprehensive manner there's so much but there are a couple things that i'd love to just highlight that i have found very helpful and i'd love to kind of hear your you expand on them one is opposite action which is um you know for anybody who's done dvt you'll grin when you just or grimace depending on because how hard it can be sometimes right um do you want to explain to people what opposite action is and when we use it i think you know what's the use case for this yeah i did my dissertation on apple oh i didn't know that actually i did okay so opposite action is a skill that falls into the emotion regulation module and it's a skill for changing an emotion that you don't want to have and it's simple in concept and hard to execute because simply put it's engaging in the opposite of what your urges are telling you to do so we know and that's why it's called opposite action so we know that from emotion science from our own experiences that our experience of emotions are associated with an urge to act in particular ways so when we feel sad we have an urge to retreat um or withdraw when we experience anger we have an urge to lash out when we experience shame it's to hide fear it's to fight or flight um and so what opposite action says is that when your emotion um does not fit the facts of the situation or is too intense for the situation and you want to change it a way to change it is to act opposite to your urges so when i'm sad instead of withdrawing i activate when i'm fearful instead of running away i approach kind of like the exposure we were talking about earlier when i'm experiencing shame rather than hide i actually um confront or disclose um and and so on so it is really hard to do uh but you get better at it over time i will say that if you practice i don't know if that's been your experience it it has been and i but what i want to tell you and i guess you'll appreciate this given your background especially is you know i mentioned earlier anger being a profound emotion that i'm very familiar with the other one is is um i don't know what the underlying emotion is i haven't really figured it out yet i don't think it's sadness but it produces a phenotype of needing to isolate so there's a just a desire to completely isolate so these are two areas where opposite action becomes very helpful right so with you know one of the really interesting things that if you told me this five years ago i would have never believed it but it's remarkable is the use of cold water to calm uh the nervous system in in moments of high fight or flight mode so that's part of the opposite action effect there i feel angry i'm gonna go and do something that's really calming which is take an ice shower or jump in the cold pool this is nice in the winter here in austin because we still have pools open and they're you know really cold in the winter um where i have but that's harder those are harder to do it's as you probably can imagine when you're when you're at nine out of ten activation and your desire is to scream or break something to then walk yourself back from that it's harder where i have found um opposite action to be remarkably helpful and helpful to the point where it's now the norm this this might be my biggest win so far is when all i want to do is isolate forcing myself to go and play with my kids and i remember the very first time this happened it was about a year and a half ago and for reasons i didn't understand it was a sunday morning and i just didn't want you know i wanted to sit in the office and do work and exercise and just do my own thing and be my own thing and my wife said hey we're going to go to barton creek and you know play on the rocks and throw rocks in the water and stuff and again that's the sort of thing i would have said absolutely not i'm too busy i just i'm overwhelmed i need to just do this thing and she would have accepted it she would have been upset and she would have accepted it she would have left and i was like okay let's go now i didn't want to go at all shireen i mean the thought of not getting my work done and missing a workout potentially and then going to some place where it's totally unstructured and there's going to be other kids potentially and it's going to be loud like that everything about that was unappealing and we had this amazing time doing nothing literally playing games like who could get across the creek without getting the most water in their shoes you know exactly what you'd expect and then on the way home we stopped and got a burger and fries like the last thing i'd want to do right like we did everything i would never want to do and i got home i felt great and i didn't get as much work done and you know and now that's become kind of the realism like you do that enough times that you realize this really works this is the key to for me this is important when i don't want to engage with anybody go and engage with my family because that's by that's the drug to get out of this so yeah i think opposite action is really a remarkable tool even the think of a simpler one smiling when you're furious [Music] and meaning it right so what marcia talks about is this opposite action all the way because if we all know what a fake smile is and a fake smile while you're also in your mind thinking oh what an i hate this person you know like that's not opposite action because that's what we might say half-assed opposite action and it's not gonna work um because your mind is still going to be angry but what's going to happen really what we're talking about with opposite action is if we act opposite to our urges we're sending the feedback back to our brain to to feel a different way right so approaching i think for a lot of people relate to the idea of doing opposite action like what you said but also with when you're feeling socially anxious like you want to avoid going to the party or speaking up in class or at work because you're anxious and maybe you have a long history of avoiding saying anything or doing anything because you're anxious so opposite action would be to say throw yourself into that go to that party even though you don't want to and then throw yourself into the party which is what you described with your family like you could have gone along physically but all the while been thinking i've been sitting there on my phone or goofing off yeah yeah or thinking this is stupid or whatever but you threw yourself into it when you were there and i think that that's the the critical piece it's not just the moving your body there it's throwing your mind into it as well so what else do you think could be really interesting for a person who's never heard of dbt to kind of understand as they themselves contemplate hey is this something is this a new skill i should learn right it's it's no different than saying i'd like to learn tennis because i know that as i age full court basketball might be hard for me but tennis is something that i'll be able to play for longer therefore i want to go and learn this skill i'm going to need a coach i'm going to need to practice and a year from now i'll be better than i am today but i mean is that do you think that's a good way to think about dbt well i do with with some caveats so you know anybody who reads any news uh or is living their lives right now knows that what we're hearing about is the idea that we're in a mental health crisis or that there's endless mental health crises right now and what we know is that there are just simply not enough mental health providers to treat all the need that's out there and what that has meant on a practical level is that there are huge long waiting lists for treatment everywhere um for most people and uh and i don't think that we don't want that to deter people from seeking out help when they need it but the point i want to make as it relates to that is that i don't think everybody needs full-on dbt and um and we don't yet have this science really this is actually an area of research that i'm interested in is trying to figure out who does need the full package of dbt versus who can benefit from a lighter touch a lower dose you know whatever word you want to use there because we want to be efficient in our mental health delivery we also want people to learn um uh to reduce suffering of people on a on a mass level so is dbt something that's sort of interrupted just to kind of this will fit into what you're saying is dbt something that can be done somewhat effectively on your own meaning with manuals with books with videos online um versus the way you would work with you know people who are much sicker where you have to be working with them directly in person so this is what we don't know yet i think we have some assumptions about this um but i don't even know if our assumptions are that valid but i think uh you know the assumption was always for example that if somebody is experiencing suicidal thoughts they absolutely need you know some form of treatment and it needs to be in person and it needs you know to be x y and z and i think covet actually threw us into this new world that we weren't expecting um because we had to start treating people who were suicidal virtually for example and we were able to realize that this idea that we had to see people in person was a myth that we believed and there were reasons why we believed it but but there doesn't seem to be any uh as far as we know so far any added risk of seeing somebody through telehealth when they're suicidal so i think a lot of our assumptions about what people need are our assumptions that we don't actually know a lot about so one of an area of research that i'm interested in and that i actually applied for some funding to do is to do kind of a stepped care model of dbt to start everybody with what we might call a low-dose intervention like videos of skills and see what percentage of people benefit from that and from that alone versus what percentage of people don't benefit enough need something else and then what can we add to that that would be a slightly step up like maybe some phone coaching you get a call with somebody once a week about how to apply the skills in your daily life then then test it again right and then if you're not responding to that maybe then you get offered the full package of dbt or something else and we basically can identify through that kind of study what are the sequences of care that are going to be most effective that will help the most people and can be disseminable so that's that's an area of research that i would love to do we don't have a lot of knowledge about that so i'll but i'll say and i think we spoke about this very early on is that i honestly believe that anybody could benefit from learning dbt skills and so to that end i would say yes i think there is a value to your listeners to say expose yourself to some of these skills see if and there are videos there are books there are things that you could do to learn more about them um see if you resonate with them see if you can apply them on your own and if you want to know more or you're struggling to apply it in your life then that might be where you could reach out for for help and find a dbt therapist now speaking of that step shireen how does a person know when they find the dbt therapist how can they verify that they're you know well trained i mean you're probably an exception in that you trained directly with marsha um there are obviously a number of people who train directly with her but you know that's not scalable so at some point you're going to meet a potentially wonderful therapist who doesn't have that that lineage so how how is um how is the field of dbt self-regulated or self-policed so it's been a long-standing process uh to try to figure this out and you know mental health is really screwing in this way because there are so many ways in which a person can provide can become a therapist hang a shingle outside their window and practice therapy and and that person can call themselves a dbt therapist or a cbt therapist or any kind of therapist and and may not have the credentials or training to back that up so i would i always tell people to kind of proceed with caution and to do your research when you're looking into finding a mental health provider so we marcia was against this for a long time she was against this idea of certifying dbt therapists she she didn't want to have a regulatory role she wanted people to learn dbt and to just sort of get dbt out there but then she was hearing more and more stories as we all have now of people saying that they received dbt and it didn't work and then you asked them what happened in their treatment and you hear details about their treatment that were clearly not dbt and so there's and and you know the worst case scenario is somebody um dies by suicide or you know has a terrible outcome um thinking that they're getting dbt when they're not so a few years ago she started the linehan board of certification lbc which has started a certification process for dbt therapists so what i will say is that um what's the logic here that i'm finding the hard time describing it but so all people that are certified by lbc to be dbt clinicians are likely good clinicians good dbt clinicians because they've met all of these standards but not all people who are not certified are bad dvt therapists right because there's a number of dbt therapists who have just elected not to go through the process of certification so if you're first starting to to think seriously about dbt you might start by looking up certified dbt therapists but recognizing that that's not the only criteria to use are there any other questions that a person can ask to determine if the pedigree of the person who's going to be conducting their therapy is truly in line with the principles of dbt as opposed to you know something that's been bastardized uh and and sort of misused so i'll share another marcia anecdote in response to that question because uh relatively early on sort of after the initial trials of dbt were put out showing that dbt was effective insurance companies started getting interested and wanted to pay for dbt but didn't want to pay for non-dbt and so they would call marsha up and they would say this person says they're doing dbt how do we know if they're really doing dbt so that we can reimburse for the service and she thought about it and ultimately said ask them if they're asked the dbt provider if they're on a consultation team now i think that this is oversimplified by far but i'll explain that one of the aspects of dbt or one of the components of the full package of dbt in addition to individual therapy and skills training is that the dbt therapist him or herself attends a weekly consultation team meeting with other dbt therapists and the consultation team meeting is a place where dbt therapists talk about their experiences delivering dbt with an aim towards improving their own adherence to the model and their motivation it's often called therapy for the therapist and uh and i think marsha's response to that question was important because in many places somebody might say i want to learn dbt and i can a provider might say oh i've learned the dbt skills and i can teach my clients dbt skills and i'll just you know pick and choose what i want to do out of dbt and the first thing they elect to drop is the consultation team meeting because it's time right it's time and effort and it's and it's centered on you and proving yourself as a therapist so i think it's i think it holds up though as a reasonable question to know to what extent is the person that you're that you're looking into adhering to dbt principles is to ask whether they're part of a dbt consultation team that's a that's a great litmus test actually i really like that i don't know how many people yeah i mean i don't it'd be interesting i mean it's funny because i hear andy talk about his um not surprisingly but i never really thought of it as a great litmus test as well so yeah sharing this was fantastic and i know we're going to get to meet in person in about six weeks so i'm really looking forward to that but uh thank you so much for your for your time uh today and i think you know this is a hard topic because it's so big and it's so big to get your arms around it all and i want people to come away from this not at all thinking that they know what dbt is necessarily from this but i hope we've peaked someone's curiosity such that they go out they they watch some videos they maybe pick up a book or a skills book and decide hey is there something in here for me and and maybe for some it means going as far as you know someone like me has gone and saying i'm going to make this a regular part of my training yeah great it was really fun talking to you so thank you thanks [Music]

Channel: Peter Attia MD

Views: 84,081

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Id: qA2sgsxImM8

Length: 156min 4sec (9364 seconds)

Published: Mon Aug 22 2022