The Peter Attia Drive - #219 ‒ Dialectical behavior therapy (DBT)： skills for overcoming depression , emotional dysregulation, and more ｜ Shireen Rizvi, Ph.D., ABPP

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:00:41.720 head over to peteratiyahmd.com forward slash subscribe. Now, without further delay,

00:00:47.740 here's today's episode. My guest this week is Shireen Rizvi. Shireen is a professor of clinical

00:00:55.080 psychology and psychiatry at Rutgers University, where she also serves as the director of the

00:00:59.760 dialectical behavioral therapy clinic. She earned her doctorate in clinical psychology from the

00:01:04.060 University of Washington, where she studied under Dr. Marshall Linehan, the creator of

00:01:08.240 dialectical behavioral therapy, abbreviated DBT. Since joining the faculty at Rutgers in 2009,

00:01:14.400 Shireen has taught courses and conducted research on topics including DBT, cognitive behavioral therapy,

00:01:20.020 or CBT, personality disorders, and trauma. In this episode, we focus specifically on DBT.

00:01:26.520 We cover the origins of DBT and how dialectical behavioral therapy differs from its cousin,

00:01:33.040 cognitive behavioral therapy. We talk about how its creator, Marshall Linehan, came to find a need

00:01:40.160 for something beyond cognitive behavioral therapy, both to help her and to help her patients.

00:01:44.940 We talk about the structure of DBT and how it is oriented as a skills-based technique.

00:01:51.720 We talk about something called wise mind, emotional mind, and reasonable mind, and how these things

00:01:56.960 are connected. We talk about radical acceptance. We talk about different frameworks, for example,

00:02:01.520 something like Dear Man, which anyone who's done DBT will be familiar with as a framework for

00:02:05.620 interpersonal interactions. We talk about one of my favorite ideas called opposite action.

00:02:10.320 We also discuss who can benefit from DBT, how it can help children,

00:02:13.500 how mindfulness plays a part of DBT, and how someone can find a well-trained DBT therapist.

00:02:18.440 Lastly, I have a huge personal interest in this because I've been practicing DBT for two years.

00:02:23.580 And I think it's safe to say I feel like I'm barely scratching the surface of what this is about. So

00:02:27.800 I have no delusion that listening to this podcast is going to offer you everything you need to know

00:02:32.560 about DBT. But my hope is that for those of you who listen to this, who see that there might be some

00:02:37.260 benefit in this technique, your curiosity might be peaked enough that you go out, watch the educational

00:02:43.880 videos that exist on this, pick up a workbook, work your way through it, and potentially find a therapist

00:02:49.200 if you think this is something that could be helpful. So without further delay, please enjoy my

00:02:53.240 conversation with Shireen Rizvi.

00:02:55.120 Hey, Shireen, it's great to finally meet you. Not in person, but better than being on the phone,

00:03:05.240 I guess. Yes, same here. You know, people on this podcast have probably heard me in a couple of

00:03:10.800 episodes reference this thing called DBT. I've never really gone into much detail about it, but it's

00:03:17.940 something I've wanted to obviously have a dedicated podcast around, and now we're finally going to get

00:03:22.000 to do that. So maybe we can just start by defining what it is a little bit before we get into its

00:03:27.340 history, its founder, your involvement, and things like that. If you were at a party and somebody said,

00:03:33.120 Shireen, I heard that you're a DBT therapist practitioner. Can you tell me what that is? What

00:03:38.060 would you say? DBT stands for Dialectical Behavior Therapy, abbreviated DBT, and it's a form of therapy

00:03:46.480 or a form of talk therapy that is largely inspired by cognitive behavioral therapy, also abbreviated as

00:03:56.960 CBT. So we often say that DBT is a form of cognitive behavioral therapy that was designed for individuals

00:04:05.420 that have complex mental health problems and originally designed for individuals that are

00:04:13.260 suicidal or self-harming and who may meet criteria for a disorder called borderline personality

00:04:19.520 disorder. At its simplest, I would say it's a form of cognitive behavioral therapy that was designed for

00:04:25.500 more complex people or presentations. But then, of course, there's a lot more nuance beyond that.

00:04:33.940 Maybe give people a bit of background on what cognitive behavioral therapy is. I mean, that term

00:04:38.320 I've heard a lot, but truthfully, I don't know much about CBT outside of CBTI, which is cognitive

00:04:45.460 behavioral therapy for insomnia, which we have referred, I would say, over the past five or six

00:04:51.140 years, probably a dozen of our patients to CBTI practitioners. I think I can say without exception,

00:04:59.000 it has always proved to be incredibly valuable, not just incrementally valuable, but incredibly valuable.

00:05:05.620 That's the very limited experience that I have with CBT is through that one narrow lens. Is there something

00:05:10.440 more broadly we can say about CBT that then allows us to contrast it with DBT?

00:05:16.220 CBT refers to maybe a class of talk therapy and could often be used to contrast it with other kinds of

00:05:25.260 talk therapy. But some of the distinguishing features of cognitive behavioral therapy is that

00:05:30.900 it's present focused, so focused on what's happening for people right now in terms of the problems they're

00:05:37.800 experiencing, and less focused on one's history, one's childhood, less focused on the sorts of things

00:05:47.500 that have led to the person experiencing the problems that they're experiencing. So it's present

00:05:53.000 focused. And as the name implied, it's focused on working with thoughts and behaviors

00:05:59.560 that go along with the problems that people experience. So in CBTI, for example, it would be,

00:06:06.920 you know, what are the thoughts that are contributing to your insomnia? And how do we work on modifying or

00:06:12.560 changing those thoughts that you're having in order to increase the likelihood that you fall asleep or stay

00:06:18.520 asleep? What are the behaviors that you do that promote sleep? What are the behaviors that you do that get in

00:06:26.540 the way of sleep? And how do we modify that? So at its most concrete level, it really is working with

00:06:33.500 thoughts and behaviors that in the present that are contributing to your problems right now. So it's very

00:06:39.280 much an active problem solving approach. With people who don't have a lot of experience with therapy or

00:06:46.960 receiving mental health treatment, they might have an idea based on the media or TV or movies that the best

00:06:55.880 therapy is one where you just go in and talk about whatever's on your mind. And CBT and similarly,

00:07:01.860 DBT is much more structured and guided than that. And the other distinguishing feature I will say about

00:07:08.900 CBT and DBT is that it's evidence-based, meaning that we construct treatments in a way that we could

00:07:18.100 measure its effectiveness. And if we find that something is not effective for people, then it's

00:07:26.580 not likely to stay in the therapy. That's our goal anyway, is to be as empirical and scientific in our

00:07:32.740 approach as possible. So how long has CBT been around as a discipline? Probably the figure that is

00:07:40.960 associated with the beginning of CBT is a man named Aaron Beck, who died last year, I believe, at the

00:07:49.040 age of 100 or something like that number. I would say it was probably the 60s in which he first started

00:07:57.440 developing his form of cognitive therapy. He was trained as a psychoanalyst and was seeing that it

00:08:04.920 wasn't all that useful for a lot of the patients that he was treating in psychiatry. And so he started

00:08:10.380 developing an approach that was much more about changing the way people thought about themselves

00:08:17.080 and others. Let's talk about Marsha, Marsha Linhan, who's, I think it's safe to say, really the creator

00:08:23.940 and founder of DBT. Is that a fair statement? Yes, for sure. So tell me about her journey.

00:08:29.880 Presumably, she had tried CBT both as a patient and maybe even as a therapist before realizing that

00:08:37.940 there was a way that it could be improved upon for at least a subset of patients and or a subset of

00:08:42.560 problems. Would that be kind of a fair statement? Yeah. So the origin story of DBT was that originally

00:08:49.480 Marsha set out to apply what might be considered standard CBT to folks who were chronically suicidal.

00:08:59.140 Perhaps beginning in the 70s, she was receiving advanced training at Stony Brook in New York.

00:09:06.360 At that time, Stony Brook was considered one of the premier places to learn and apply behavior

00:09:13.300 therapy. And back in the days of the 70s, 80s, it was really the heyday of behaviorism. And the idea

00:09:22.320 was in many ways oversimplified, but the idea was that we could treat any mental health problem

00:09:28.660 with behavior therapy in very few sessions just by applying these standard principles of what we know

00:09:37.700 about behavior change. Can you give me an example of what that would be? Does that mean that if a

00:09:42.760 person was clinically depressed and came in and they were suicidal, what would the CBT approach have

00:09:49.600 been in the 70s or 80s to address that concern? I can come back to depression and suicide in a minute,

00:09:55.940 but I might start with anxiety disorders because this is actually what behavior therapy and CBT was

00:10:01.740 probably most prolific about in those days. And the idea was that you could have somebody who came

00:10:08.880 into treatment with a fear of something, a phobia. It could be something like a fear of heights or a fear

00:10:16.540 of spiders, or it could be a fear of social situations, social anxiety. And the behavior therapy

00:10:23.580 approach to this or the cognitive behavioral therapy approach to this would be to teach people

00:10:29.220 competing thoughts. So rather than thinking this thing will kill me, I can learn to have thoughts

00:10:39.460 like I can tolerate this. This might be difficult, but I can handle it. Or even have thoughts like this

00:10:47.620 is not going to kill me. But those thoughts were only one part of it. The other piece of it was the more

00:10:53.200 behavioral piece, which is exposure, basically saying that how you're going to get over your fear of

00:11:00.120 spiders is not to talk about it every week for an hour with somebody, but it's actually going to be

00:11:06.780 coming into contact with spiders repeatedly over and over again, so that you learn that you can handle

00:11:15.520 it. But you also learn that the feared outcome is not going to occur. Change your thoughts and get

00:11:21.080 exposure. Change your thoughts, get exposure. Exactly. And the getting exposure is changing

00:11:25.380 your behavior because you want to run away or avoid. And instead, it's saying come into contact

00:11:33.120 with approach, something that you want to avoid. And so what they were finding in these early days of

00:11:39.560 applying CBT is saying people may have gone to psychoanalysis, which was the dominant paradigm of

00:11:46.920 therapy in those days. And by the way, this is almost exclusively a rich white person issue when

00:11:54.080 I'm talking about who was receiving treatment for mental health problems. That's what I'm talking

00:11:59.180 about back in those days, largely. People could go to a psychoanalyst and talk about their fears

00:12:07.020 for months and years and not necessarily do better with them. And so CBT comes along and says,

00:12:16.240 actually, we could do this sometimes, depending on what the fear is, in one session. There were

00:12:22.900 people who would do like a three-hour session to quote-unquote cure somebody of a phobia and finding

00:12:29.380 that it worked. And so then you say, okay, how do we take those principles to something like

00:12:34.820 depression? And this is what Aaron Beck started to do with cognitive therapy more, was noticing that

00:12:41.560 people who have depression tend to think in very particular ways. They have negative interpretations

00:12:48.420 of almost everything and also about themselves, about their future, about others. And so a cognitive

00:12:57.980 behavioral approach to depression would be about working on changing those thoughts to be more

00:13:03.460 balanced and evidence-based. And then also the behavior change that goes along with depression

00:13:09.020 is usually about getting active. So when somebody is depressed, the tendency is to retreat, shut down,

00:13:17.880 avoid. And the behavioral treatments for depression would be to get people activated and to solve the

00:13:25.460 problems that are causing the depression, whether it's unhappiness with a job, unhappiness with a

00:13:31.000 relationship, and work on targeting the problems that are causing depression in a systematic way.

00:13:38.060 How successful was it? You mentioned earlier that evidence is a very important part of this.

00:13:44.100 How were they able to tally the results and determine if their intervention was in fact better

00:13:51.300 than the standard of care at the time? The history of psychotherapy trials is largely

00:13:56.320 based on a paradigm known as randomized clinical trials, where you would recruit individuals who meet

00:14:04.400 certain inclusion criteria, say somebody meets the diagnosis for depression, and then you would

00:14:10.440 randomize them to either, say, receive 12 weeks of cognitive behavioral therapy or receive nothing or

00:14:18.340 receive treatment as usual or standard of care, and then evaluate outcomes over time. And with things like

00:14:26.240 depression and anxiety disorders, there are these standard measures that are popular within our field,

00:14:33.720 where we have developed benchmarks for what we're trying to get to, you know, what might be considered a

00:14:41.220 success. And I would say that in general, the trials for CBT for things like depression and anxiety are

00:14:48.400 overwhelmingly positive, meaning that most of the trials, especially in the early days when you were

00:14:55.040 comparing CBT to nothing or treatment as usual, found very large effects for CBT in those settings. Now, I think

00:15:04.760 where we see or where we'll come back to Marcia emerging is recognizing that, of course, none of these

00:15:11.880 treatments were 100% successful for everybody. And more than that is that when you look at these studies,

00:15:19.560 and you see who were these studies done with, the inclusion criteria, meaning what allowed somebody

00:15:26.260 to be in the study, were often quite narrow. For example, with a depression study, the person might

00:15:33.080 have to meet the criteria for a diagnosis of depression, but not have suicidal behavior. So people

00:15:40.440 with suicidal behavior may be excluded from a lot of those studies, which makes sense from a research point

00:15:48.580 of view in some contexts. But in other contexts, does it make sense? Because of course, we know that

00:15:53.840 a lot of people who experience depression are also suicidal. So if you're removing suicidal people or not

00:16:00.960 allowing suicidal people to be part of this research, then we don't know, ultimately, if the treatments

00:16:08.100 work for those populations.

00:16:11.000 Marcia, as a young girl, I think, was diagnosed with schizophrenia. Is that correct? And was treated with

00:16:16.800 electroconvulsive therapy and all sorts of things that are still used today, but probably not as

00:16:21.880 frequently and probably with a bit more particular attention to the use case, probably used more

00:16:27.180 liberally than I'm guessing?

00:16:28.720 So Marcia was a teenager, I believe, at the time that she was receiving a lot of treatment. And this was

00:16:37.640 in the late 60s, if I'm remembering correctly, when she was born, now that I'm thinking about it. But

00:16:43.900 it was before CBT was really in the picture. And she was hospitalized for being suicidal and

00:16:54.280 chronically self-injuring, doing a number of things to cause physical harm to herself as a way of

00:17:01.860 relieving emotional intensity and overwhelming emotions. So at the time, there was not a lot of

00:17:09.200 treatment options that were available. And the medical model was to treat with really strong

00:17:15.980 meds, antipsychotic meds at the time, or to use something like electroconvulsive therapy.

00:17:24.820 And so those were the treatments that she was exposed to from a very young age, in addition to

00:17:30.680 therapy. But the types of therapy that she was receiving at that time were unlikely to be anything

00:17:37.800 like the cognitive behavioral treatment we know today.

00:17:41.100 So how did she find her way from being almost institutionalized to eventually getting an

00:17:47.680 education and herself becoming a therapist? What was that journey that went from that teenage girl to

00:17:53.060 the person who created DBT?

00:17:55.820 She has written about this in a memoir, as well as described it in a piece in which she,

00:18:02.240 in the New York Times, which was a piece where she kind of came out to the world as having been

00:18:08.480 someone who experienced her own significant struggles with mental health. And I say that as a preface

00:18:14.960 because for that article in the New York Times came out, I believe in 2010, 2011. So for most of her

00:18:23.800 career, she was not forthcoming about this, her own personal struggles. She would tell people that were

00:18:30.920 close to her, her students, I was one of them, knew about this experience, but she wasn't public about

00:18:38.280 it. And she would long say that the reason for that is because she wanted DBT to be judged on its

00:18:47.180 merit empirically. She did not want DBT to be judged on her personal story alone. She wanted this to be a

00:18:56.700 scientific treatment that lives and dies by its outcome, she would say. So when she would talk

00:19:02.860 about how DBT developed to the public is she would talk about it leaving out this earlier part of her

00:19:11.900 own history. So the earlier part of her own history that she describes is that she had a spiritual moment

00:19:18.060 when she was in one of these institutions. And the spiritual moment was that she describes experiencing

00:19:28.540 God in a very dark moment of her own life. And in that moment, she realized that she felt the love of

00:19:37.820 God and felt that she could serve this purpose in life, which is to get out of hell, her own experience,

00:19:46.640 and then to work her entire life to get other people out of hell. And that was how she took this

00:19:54.540 spiritual experience and developed her life's work based on that.

00:20:00.880 How old was she, Shireen, at that time?

00:20:02.800 I would say as best I remember in her late teens or early twenties.

00:20:09.000 Kind of profound to follow through on something that you could argue, well, God, you were still so

00:20:14.200 young when that was happening. And was she at some point here diagnosed as having a borderline

00:20:19.360 personality disorder as well? Or is that something that is more retrospective where it's sort of like

00:20:24.280 looking back, she was probably misdiagnosed as having schizophrenia. I mean, what was the

00:20:28.840 state of understanding of her actual condition?

00:20:32.120 I believe that she was probably, you still see this today, but when people are unclear about how to

00:20:38.300 explain someone's problems, they get given almost every diagnosis in the book. And now this would

00:20:45.840 have been before the criteria that we now know is borderline personality disorder being defined in

00:20:52.000 the way it is most well known would have started in the third edition of the DSM, which came out in

00:21:00.060 about 1980. So the criteria that we have now to define borderline personality disorder was not the same

00:21:07.380 as when she was receiving treatment. So I believe that she had a number of diagnoses attributed to

00:21:13.060 her. I can't remember. It's quite possible that borderline personality disorder was one of them

00:21:17.720 because of course, that's also the diagnosis that they give people when they don't know how to treat

00:21:22.920 them. What are the criteria? Tell folks what borderline personality disorder is today.

00:21:28.180 So borderline personality disorder is considered a complex mental health disorder. There are nine

00:21:35.700 criteria of borderline personality disorder as defined by the DSM. And in order to meet criteria or to have

00:21:41.100 the condition, you have to endorse five of the nine, which actually means that ultimately it's a really

00:21:49.000 heterogeneous disorder because there's all these different combinations and different ways in which

00:21:53.880 one can meet criteria. One of the things that Marsha did was to restructure the different criteria of 1.00

00:22:01.860 borderline personality disorder in a way that perhaps is more understandable and also makes more cohesive

00:22:07.360 sense. And to say that it's a disorder of dysregulation across a number of different domains.

00:22:14.500 So the core domain of dysregulation that we see in borderline personality disorder is what we refer to as

00:22:20.260 emotion dysregulation. And this is largely defined by people's experience of emotions as feeling

00:22:27.460 like they have very intense emotions. They don't feel like they can control their emotions very well.

00:22:35.800 Their emotions change very rapidly. So that's referred to as affective lability, that the emotions will go

00:22:44.180 from intense sadness to intense shame, to fear, to joy, you know, very quickly and seemingly without a lot of

00:22:53.760 reason. So emotion dysregulation is part and considered core to the disorder of borderline personality disorder.

00:23:01.760 And then these other domains of dysregulation stem from emotion dysregulation and include behavior

00:23:09.300 dysregulation. So not having control over or feeling like you don't have control over your behaviors. This is

00:23:18.000 associated with a lot of impulsivity and behaviors that go along with impulsivity. So substance use,

00:23:25.920 reckless spending, impulsive sexual behavior, impulsive driving, behaviors that are experienced as

00:23:35.640 impulsive and potentially could cause problems for the person. Impulsive eating is another.

00:23:41.900 I mean, it sounds like there's quite an overlap, at least in some of those with bipolar disorder,

00:23:46.040 right? Bipolar one. I don't know about the affective lability, but certainly the main side of it sounds

00:23:52.100 like it might be consistent with some of that dysregulation. I'm guessing that's what makes

00:23:55.940 psychiatry so difficult is you don't have biomarkers. You don't have imaging scans that give you

00:24:02.260 diagnoses, right? We don't. And so there is, you're right, a lot of overlap and probably the ones,

00:24:07.880 the overlap that is more consistent or difficult to discriminate is bipolar two because bipolar one

00:24:16.140 is associated with longer lengths of either a pure manic state or a pure depressed state. Bipolar two

00:24:24.400 might have manic states, but it is shorter in duration or might not be super manic, right? As high.

00:24:32.480 And so that's often really hard to discriminate from somebody who has borderline personality disorder.

00:24:39.460 And generally what we're talking about with BPD as opposed to bipolar is that we actually see the mood

00:24:45.740 changes happening more frequently within BPD than with bipolar two, but I'm probably oversimplifying,

00:24:53.900 but that's what I would be looking for if I was trying to assess the difference.

00:24:58.020 A person with BPD, what are the challenges that they face in the world? Let's just assume this

00:25:04.320 is a person of totally normal intelligence and all physical capabilities are fine. And this is sort of

00:25:09.800 the one issue, this one psychological issue. How does it manifest itself for that person when they're

00:25:16.260 in school, when they're in college, if they get married, if they have kids, like help us understand

00:25:20.880 how this condition makes life more difficult for the individual and those around them.

00:25:27.220 One thing I'll say is that you rarely will see this condition in isolation of anything else. And

00:25:35.140 again, this speaks to one of the complexities of trying to study psychiatry that I think on average

00:25:41.340 people who meet criteria for BPD have three to four other mental health problems at the same time.

00:25:48.300 So they'll also meet criteria for depression or an anxiety disorder or a substance use disorder or...

00:25:54.220 And those things aren't stemming from the BPD? These things are, we believe, independently there as

00:26:01.380 well?

00:26:02.140 I think it depends on who you ask, because I would say as somebody who is trained mostly behaviorally,

00:26:08.040 I would say the diagnosis matters less than how we conceptualize these problems. And to that point,

00:26:14.820 I would agree with you. We could say emotion dysregulation is central to all of those things.

00:26:19.460 But the diagnostic system, as we currently have it, does not allow for that. So they would say,

00:26:25.620 if somebody meets criteria for these other disorders, they also have these other disorders.

00:26:30.860 So how somebody with borderline personality disorder lives their lives, I would say,

00:26:37.240 it's complicated and it ranges. On one end of the continuum, we see people who have severe problems

00:26:45.660 associated with BPD such that they struggle to hold on to a job. So they don't work and they're on

00:26:52.260 disability or receiving social security. They can't maintain relationships.

00:26:58.180 And why is that? Why are relationships blowing up? And why are they not able to hold down a job?

00:27:02.960 What's the fundamental issue or fundamental issues that are impairing them?

00:27:07.540 From a DBT perspective, we would say that it all comes back to difficulty regulating emotions.

00:27:16.000 So that if I experience intense emotions that I feel like I can't control, when I get angry,

00:27:25.980 I lash out. When I get scared, I run away or avoid. One of the criteria that goes along with BPD that you

00:27:34.800 could see is tied with emotion dysregulation problems is what's referred to as fears of

00:27:39.800 abandonment. So a person with BPD often will have a lot of fear that a person that they love or are

00:27:50.180 close to will leave them. And if I am in a relationship where I am afraid that the other person is going to

00:27:58.100 leave me all the time, that may cause me to behave in ways that are frantic, chaotic, and actually

00:28:10.080 paradoxically have the effect of causing the other person to be more likely to leave. Texting the person,

00:28:17.100 calling the person relentlessly. If a person doesn't come home or call at the time that they say they

00:28:24.880 will, you know, having the experience of feeling like I'm losing it because I don't know where that

00:28:29.800 person is, or perhaps they've left me. As a result, if I have BPD, I experience intense fear, intense

00:28:38.420 shame, intense sadness. And now I don't know what to do with this intense behavior. And I may self injure

00:28:45.700 as a way of relieving that emotional intensity, or I may threaten suicide as a way of getting the

00:28:54.640 person to come back to me. And maybe I'm doing this without even having awareness that that's the

00:29:00.800 effect of my behavior. I just know that in this moment, I don't know what to do. I feel entirely

00:29:06.760 out of control and I need to do something to fix it in this moment. What is the mortality of BPD?

00:29:15.060 I was very surprised to learn recently that anorexia nervosa has probably the highest mortality

00:29:20.120 of any psychiatric condition. I would have guessed depression, presumably. Where does BPD stand in

00:29:27.100 terms of mortality, either through self-harm and neglect, potentially, or obviously suicide?

00:29:33.420 I sometimes get into the weeds a little bit about this. And when, as an academic and psychologist,

00:29:39.280 what I, and someone who studies suicide, I review a lot of manuscripts and grant proposals,

00:29:45.240 proposals. And I am always saddened and amused when I see people write about a disorder and say,

00:29:52.440 this disorder has one of the highest rates of suicide. Because if you look at it, it seems like

00:29:57.320 every disorder has one of the highest rates of suicide. And I think it's because we don't know

00:30:02.220 how to study this very well. Honestly, we don't know how to determine of the people who die by suicide,

00:30:09.540 what are the mental health conditions that they had? And what is the relative risk according to

00:30:17.620 these different disorders? Well, especially when you overlap, because as you said earlier,

00:30:22.320 if a person with BPD also suffers significant depression, if they commit suicide, are we

00:30:27.720 attributing that to depression? I think my question more broadly is, knowing that one could never tease

00:30:32.900 that out. How risky is it for an individual understanding all of the comorbidities that tend

00:30:39.240 to cluster with it? I will say it's very high. And one way in which I can answer this is another

00:30:45.880 criteria for BPD is repeated or chronic self-injury or suicide attempts. More than 75% of people, and in some

00:30:57.100 studies, 90 to 95% of people who meet criteria for borderline personality disorder engage in self-injury

00:31:05.060 or have made more than one suicide attempt in their lives. This tells us a couple of things. One is that

00:31:12.760 that on its own is considered a very high-risk behavior because people who engage in self-injury,

00:31:19.840 even if they don't intend to die, there could be accidental death as a result of self-injury.

00:31:25.440 What are some examples? I mean, people probably think of the most common examples of people

00:31:29.540 cutting themselves or burning themselves. What are some other examples of self-injurious

00:31:33.720 behavior that people engage in? Headbanging or punching or hitting oneself. There are multiple

00:31:41.960 forms of cutting that include different objects to cut, but could also be people really intensely

00:31:50.320 scratching themselves to the point where they draw blood. There's overdosing is considered a form of

00:31:57.740 self-injury. You know, you have to determine, is this with intent to die or not? But there are people

00:32:02.940 who overdose without intent to die as a way of hurting themselves. More rare, but other forms of

00:32:09.760 self-injury may involve ingesting toxic substances, et cetera. So this is also, I think, evolved over time

00:32:19.720 or we didn't know how to study it very well over the years because even in my career, I feel like 20

00:32:26.940 years ago when we were talking about self-injury, we were talking much more about things like cutting or

00:32:32.860 burning. And I feel like as there have been more people interested in studying self-injury,

00:32:39.620 we're also finding out about other ways in which people cause harm to themselves. And then there's

00:32:47.520 all sorts of debates about whether this is considered self-injury or not, because some people might say,

00:32:53.400 I have binge eating or I overeat. And I do that intentionally, even though I know it's causing harm to

00:33:00.140 myself, whether we classify that diagnostically as self-harm or not is one question, but whether

00:33:07.680 a person considers themselves actively doing harm to themselves, that's another question.

00:33:13.300 What's the male-female split in BPD?

00:33:16.140 So that's another thing that's changed over time. It was long thought to be a female disorder, 1.00

00:33:21.940 and there's all sorts of reasons for that. A lot of them are sexist. Now we see more studies

00:33:30.060 that indicate that there are roughly equivalent rates among men and women. However, there's still

00:33:37.700 a bias, a diagnostic bias for tending to diagnose women more often as BPD intending not to diagnose

00:33:46.400 men with BPD. So does that mean under-diagnosing men over-diagnosing women potentially?

00:33:52.980 I think so. I think the under-diagnosing of men has been shown in a number of studies,

00:33:57.980 and it appears that men have to be more severe in order to receive the diagnosis than women.

00:34:06.920 Whether women are over-diagnosed, I'm not sure, but I think it's very rare that you would see

00:34:12.100 a psychiatrist or a medical professional do a diagnostic assessment. I think it's much more

00:34:19.660 likely that they base that diagnosis on, is this person difficult in some way?

00:34:26.180 So when you look at the twin concordant studies of things ranging from autism to depression,

00:34:31.880 you see a very strong genetic component to these things. Do you have a sense of how strong the

00:34:39.340 genetic link is for BPD, presumably based on these identical twin discordant studies,

00:34:45.260 identical twins raised separately and looking at the prevalence? How much of this is genetic,

00:34:50.260 and then how much of this is environmental where life events trigger a susceptible individual

00:34:57.620 to manifest the traits? So I don't know the data off the top of my head about the twin concordance,

00:35:04.300 but I would say there's a general understanding that there is, of course, a genetic component to

00:35:09.680 this disorder. And I would say that the DBT framework is one that has a model for explaining how BPD

00:35:18.880 develops, which we can probably get into, but that speaks to the fact that there is both a genetic

00:35:24.520 and an environmental component to the development of the disorder.

00:35:29.660 So let's go back to Marsha and her journey. So she has this, you know, literally come to Jesus,

00:35:34.820 right? So she has this kind of epiphany in her late teens or early twenties, which it sounds like

00:35:39.760 puts her on a different path, potentially saves her life. It's still a long way from there to where we

00:35:46.500 are today. So walk us through that journey. So this is where it picks up in terms of the story

00:35:52.560 that is part of the development of DBT story. Now leaving out her own personal history, you know,

00:36:00.540 Marsha went on to get a degree. I should also point out that I think one of the factors that led to

00:36:07.160 Marsha being able to do this is that I think she's hands down a genius. And so that was probably, 0.98

00:36:12.980 despite her really difficult experiences, she had this amazing capacity that helped her,

00:36:23.500 I'm sure in numerous ways, including developing this treatment. But so she went on to get a degree

00:36:29.580 in social psychology, a social psychology PhD, which is a little known fact about her that she

00:36:35.660 doesn't have a degree in clinical psychology, but she got her social psychology degree, but then decided

00:36:40.520 that she wanted to get clinical training. And that's what led her to this training experience

00:36:45.740 at Stony Brook, which is where they were doing a lot of work on theory and treatment related to

00:36:52.680 cognitive behavioral treatments for a range of disorders. And at that time, nobody was studying

00:36:58.200 cognitive behavioral treatment for suicidal populations. And so Marsha decided,

00:37:04.080 I want to take what we know about CBT that seems to be hugely effective for all of these disorders.

00:37:11.060 And I want to take all that we know about CBT and just plop it into treating chronically suicidal

00:37:18.200 individuals. The way she reports it is saying she wasn't interested at that time in diagnosis. She

00:37:24.880 just wanted to work with people who chronically experienced urges to die. That's what she attempted to do.

00:37:32.240 And by her accounts, this quickly blew up. Just for timing, this is now the early 80s?

00:37:38.000 Yes. Late 70s, early 80s when she did her fellowship there. And do we have a sense of how

00:37:46.640 she is treating herself at this point? In other words, how is she regulating her own emotions? Are

00:37:52.880 the tools of CBT things that she is finding helpful for her own self-care? This is a great question.

00:37:59.880 And I'm not sure I know what the answer is. And what's interesting is that I think that what

00:38:04.960 Marsha did was she took a lot of her own experiences, and then she was able to translate that

00:38:10.700 into cognitive behavioral terms, which led to the development of a lot of the skills in CBT that she

00:38:18.040 developed for people. Whether she was thinking at the time about applying CBT to herself, I don't know.

00:38:25.500 But I think that that's what she ended up doing by developing these skills. 0.92

00:38:30.980 She sort of became the index case, right? She was not necessarily thinking it this way,

00:38:35.660 but she was working out the tools of how do you transition. I sort of liken that to what Bruce

00:38:40.920 Lee did. I don't know how familiar you are with Bruce Lee, but most people sort of know him as kind

00:38:44.800 of a movie star in martial arts. But he was far more relevant in creating a system of martial arts

00:38:49.620 called Jeet Kune Do, which took from over 30 different other styles of martial arts, and in

00:38:56.660 his words, took what was useful and discarded what was useless, and created a new system with a very

00:39:04.280 particular goal, by the way. So he had a very clear objective in what Jeet Kune Do was to be about.

00:39:09.160 And in some ways, it's almost like that's what Marsha was doing on herself.

00:39:13.100 Yes, on herself and also in her treatment development work, which is a very iterative

00:39:20.360 process. Like, let me try this. Does this work? I'll keep it. Does it not work? I'll throw it out.

00:39:26.620 If it works, what is it? How do I define it? How do I write about it in a way that other people

00:39:33.140 can do it and put it all together in a package? Again, I think this speaks to how brilliant I think

00:39:39.820 she is that she could do it. But it does align with what you're describing, which is, and what's

00:39:44.820 I think really exciting about treatment development work is this whole process of figuring it out as

00:39:50.800 you go, and then trying to replicate it, and really using the client's experience to say,

00:39:57.120 is this having the intended effect? So I interrupted you, but let's go back to Marsha at Stony Brook

00:40:03.120 and finding out that CBT in its current form is not helping suicidal patients, at least not to a

00:40:12.220 level that she's feeling is successful, right? Right. So what she, again, this is secondhand,

00:40:17.960 so I just tell the story as though I'm her, but what she would report is, okay, I go into my session

00:40:23.800 with somebody and I ask them about what are all the problems that you're experiencing that is causing

00:40:30.160 you to feel suicidal? And the person would say, I hate my job. You know, I hate my relationships.

00:40:36.340 I don't have any pleasure in my life, whatever those things are. And Marsha with the CBT lens would 1.00

00:40:42.360 say, we can figure this all out. We'll just take all of your problems. We'll put them on the list.

00:40:47.820 We'll systematically go through each of your problem one by one, which we'll solve. We'll figure this out

00:40:53.620 in no time. And the way she reports it is that she did that feeling all the hope in the world.

00:40:59.720 And the reaction that she got was totally unexpected, which is people saying, you have

00:41:05.440 no idea. You have no idea how bad my problems are. If you thought that these are things that

00:41:13.260 are easy to solve, you are sorely misunderstanding the depths of my problem. You clearly don't

00:41:20.560 understand anything about me or my situation if you think that these are things that could

00:41:25.060 be easily solved. More than that, if these were easily solved, I would have solved them

00:41:30.420 a long time ago. You have no idea how much I'm suffering, right? You don't get it. So this

00:41:36.220 iterative process was like, okay, this blew up. This isn't working the way I intended. And so the

00:41:42.800 next piece of her story is she would say, okay, that's not working. I need to figure out what's going

00:41:48.780 to work. She took the other perspective and she said, okay, what they're telling me is that I don't

00:41:54.440 understand the depths of their problems. And maybe that's true. And so what I need to do now

00:42:00.580 is tell them and work with them to completely understand. And so she would go into her sessions

00:42:06.860 with people who are chronically suicidal and say, you're right. Your problems are too difficult.

00:42:14.220 You've had longstanding experiences with trauma. You've been treated terribly your whole life.

00:42:23.340 You have a number of obstacles that may prevent you from getting the job that you want or the

00:42:29.040 relationship that you want. And perhaps what we need to do is work on accepting your life as it is

00:42:39.800 and finding joy in that, but accepting the life as you have it and let go of trying to solve all

00:42:47.520 these problems. And so that was her next step. And this is the epiphany that of course, anyone who's

00:42:54.060 done DBT knows is radical acceptance. Well, it wasn't quite labeled that yet. What she would...

00:42:58.660 Was this kind of the precursor of what we would now describe as...

00:43:02.160 Yes, I think it could be the precursor, but it was missing something because what she would say is

00:43:06.840 this is the acceptance piece. But when she tried it thinking, oh, this is what people want,

00:43:13.640 you know, they're saying I can't solve their problems. And so clearly if I communicate that I

00:43:18.740 understand how difficult things are and we can work on accepting it, the reaction she got then was what?

00:43:27.200 There's no hope.

00:43:28.340 How can you say that I should just accept this? My life is miserable as it currently is. You know,

00:43:34.680 if I accept this, there's no hope. I should just die. Again, you don't possibly understand, 0.99

00:43:40.220 you know, everything. DBT stands for dialectical behavior therapy. We can talk about dialectics,

00:43:45.640 but this is what turned into the idea of this primary dialectic in this treatment, which is the

00:43:52.600 dialectic between change and acceptance. And figuring out how do I, as a therapist, as a

00:43:58.660 treatment provider, straddle this line, synthesize this, because both of these are important. We need

00:44:05.360 to work on solving the problems in your life that are causing you such distress and misery. And we also

00:44:11.360 need to work on accepting your life as it is and accepting the things that we can't change about our

00:44:18.620 lives. But how do we do that in a way that is palatable to the person on the other end,

00:44:26.480 and in a way that conveys hope that things could change? And so it's about synthesizing

00:44:31.500 those two elements. And I think it's the synthesis of those elements that lead to things like radical

00:44:37.960 acceptance and other components of the treatment.

00:44:41.680 So this is probably a great time to double click on what dialectical means, because I'm not sure if

00:44:47.580 it's innate to us. I think it requires some practice.

00:44:51.000 I was listening to some interview the other day where somebody just simply said,

00:44:54.740 humans don't like contradiction. That's true. We don't like contradiction. And so dialectics is

00:45:00.760 really, by the way, I'm no expert in dialectical philosophy, as Marx initially wrote about it. I'm more

00:45:08.100 a student of dialectics as it informs my life and my practice. But dialectics is this understanding

00:45:15.520 that there is contradiction and opposition and tension in everything. And therefore, we can't

00:45:26.220 avoid it. And the more we try to avoid conflict and tension, the more likely it is that we're going to

00:45:33.540 see conflict and tension. So dialectics, at least, again, in the practice of DBT is the practice of

00:45:41.840 recognizing tensions as they exist, polarization as it comes up, and then striving to find what is valid

00:45:52.540 about both sides, or both sides of the tension and seeking to find a synthesis, some new argument or new

00:46:01.880 statement that recognizes and adopts the validity in the two opposing sides.

00:46:08.740 A reasonable time to jump forward. And then I want to come back because I love this story. But if a person

00:46:13.620 listening to this or watching this has ever kind of gone through DBT, then they're familiar with the workbook.

00:46:17.720 You're doing this in a very structured way. And one of the first images in the workbook is the two

00:46:23.220 intersecting circles of wise mind and emotional mind.

00:46:27.480 Emotional mind and reasonable mind.

00:46:29.140 I'm sorry, reasonable mind. Yeah, wise mind being the intersection. Can we use that as an example

00:46:33.140 of dialectical synthesis where you have those two minds intersecting, and then that union or

00:46:39.500 intersection of them being the wise mind? And how do we find those? Again, contrasting it with

00:46:43.560 emotional and reasonable mind.

00:46:45.620 That's exactly right, that that is an illustration, a key illustration of dialectics at play is this

00:46:52.640 notion of wise mind. And wise mind being a skill in the workbook that we teach people as something that

00:46:59.580 we are striving to access wise mind more often in our lives. And that accessing wise mind involves

00:47:08.960 synthesizing these two tensions potentially or polarizations known as emotion mind and reasonable mind.

00:47:17.680 Emotion mind is the idea that a state in which we are completely controlled by our emotions.

00:47:24.680 So when we're angry, it could be lashing out at somebody, it could be engaging in physical violence,

00:47:33.680 it could be threatening physical violence, it could be slamming doors, could be quitting things, you know,

00:47:39.680 all the things that we might do when we're being controlled by the anger we're experiencing.

00:47:43.680 Reasonable mind, on the other hand, is when we're controlled kind of by facts and logic,

00:47:49.840 we're not aware of or experiencing any strong emotion, you could imagine or you can envision

00:47:56.880 the tension that exists between these two. If you've ever been in emotion mind having an argument with

00:48:04.120 somebody in reasonable mind, or vice versa, because that happens a lot. I think it has happened in my

00:48:11.320 marriage, it probably happens a lot across many people's marriages, where one person is in emotion

00:48:16.840 mind, the other person is in reasonable mind. And that's a recipe for really strong conflict. So wise

00:48:24.200 mind is saying, what's valid about the emotion that I'm experiencing here? What's valid about reasonable

00:48:32.600 mind that I'm experiencing here? And what's a synthesis? So a silly story that we might tell to

00:48:37.800 illustrate wise mind or emotion mind is, you're walking down the street, and you pass by a pet store,

00:48:46.360 and in the window are a dozen puppies. Or if you're a cat person, imagine a dozen kittens, okay?

00:48:55.400 Emotion mind takes over and says, I want all the puppies, every single one of them, because this one is 0.77

00:49:03.640 cute for this reason, this one is cute for this other reason, oh my god, they would be so happy

00:49:07.480 together. And I would be so happy if I had all these puppies in my life. I want them. So emotion mind

00:49:12.840 says, get all the puppies. Reasonable mind says, oh my gosh, dogs are so much work. You have to walk them

00:49:22.360 three times a day. They're expensive, you have to get all this equipment, you have to get a veterinarian,

00:49:31.080 you have to restructure your time so that you spend more time with the dogs or not, you have to

00:49:37.080 reimagine your whole life around that. So reasonable mind might say, no puppies, puppies are never for you.

00:49:44.440 So what does wise mind say? Well, what's great about even teaching this as an idea is that wise mind

00:49:50.600 is not a synthesis, a dialectical synthesis is not a compromise. It's not a halfway point. Because if I

00:49:58.320 were to say that, then wise mind would say, get six of the puppies if there are 12. And that makes no

00:50:03.720 sense as a compromise or as a synthesis, because it's not seeing the validity in both sides. So what

00:50:12.720 would wise mind be? That would vary depending on the person, because for some people, a wise mind decision

00:50:18.640 would be to bring home a puppy. For other people, a wise mind decision would be to say, now is not the

00:50:26.180 right time for me to have a puppy, but I am going to do X, Y, and Z in order to increase the likelihood

00:50:32.620 that I can have a puppy in the future. Wise mind might be, I have the perfect scenario now, I can

00:50:38.660 bring home two puppies and we will live happily ever after. So it's going to vary. But the idea of

00:50:44.020 finding this synthesis is about seeing what's valid and true about both ends of the, or both of the

00:50:52.100 sides, and then trying to figure out what a synthesis could be. One of the things I'm struck by when I

00:50:57.980 look at the notebook, the workbook that we use in DBT is how much is in it. To think that this is the work

00:51:05.420 of largely one individual, and obviously it's been iterated on, but can we go back to the story of

00:51:11.840 some of the earliest insights she had treating some of the most in-need patients, and how she basically

00:51:21.400 then realized she couldn't do what she was doing under the umbrella of CBT and needed to make this

00:51:28.100 change from the cognitive to the dialectical and create another form of behavioral therapy.

00:51:33.720 You know, getting back to where she was in terms of realizing that if I push for change, too hard,

00:51:40.960 disaster happens. If I push for acceptance too hard, disaster happens. What can I do to find

00:51:48.560 the middle? How do I balance these two things? Again, part of the lore of the story of DBT was that

00:51:56.000 she was writing about this idea of balancing change and acceptance. And these were the days where she

00:52:05.060 would write up notes, either handwritten or on a typewriter, and hand them over to a secretary who

00:52:11.600 would type them up or revise them. Her story is that her assistant that was working on typing this

00:52:18.160 all up came to her one day and said, my husband is a graduate student in philosophy. We were looking

00:52:25.440 at this, and we think that what you're describing actually is something that he studies and is called

00:52:31.300 dialectics. So according to Marcia, she didn't know anything about dialectical philosophy

00:52:36.480 as she was iterating this treatment. And this was one of those happenstance moments that came to her.

00:52:43.520 And then, of course, she sought out readings, descriptions of dialectical philosophy and saw,

00:52:48.840 yes, that is exactly what she's thinking. And that dialectical philosophy informs a lot of science

00:52:58.180 and scientific thought, and so actually worked well within the paradigm of the development of

00:53:08.240 cognitive behavioral treatments. So that's where DBT started to take form. If you're familiar with

00:53:15.980 her books, you know that her original treatment manual that was published in 1993, and also the

00:53:21.620 original skills workbook that was published in 1993, says on the cover, cognitive behavioral therapy

00:53:27.560 for borderline personality disorder. Oh, I wasn't aware of that.

00:53:31.000 Yeah. The newer edition says dialectical because she was told at the time by the publishers that

00:53:35.840 nobody will know what this means, and nobody will want it. That may be true. It's possible that

00:53:42.020 if it was called dialectical behavior therapy on the cover of the book back then, it would not have

00:53:48.540 actually been as popular as it is now. Now, of course, we can put dialectical behavior therapy on the

00:53:54.920 cover of any book, and people will see the value in it, but I don't think that was true then.

00:54:01.380 When did she develop her own interest in Zen philosophy and the practice of mindfulness,

00:54:07.600 which also is a very important muscle that one develops as they move along their DBT journey?

00:54:15.220 Was this something that had been more longstanding with her?

00:54:17.800 I think that this was all happening around the same time. Marsha grew up in a Catholic family,

00:54:26.460 identified as a very religious person, identified as saying that at one point she thought she was

00:54:33.200 going to become a nun. And so this was a large part of her upbringing, also was part of that

00:54:40.180 spiritual experience that she had personally. And another reason, by the way, that she didn't want 0.99

00:54:46.140 to come public with her story early on, is that she didn't want the lesson to be, oh, if you want

00:54:52.820 to get better, you also have to have a spiritual experience. Instead, what she wanted to figure out

00:54:59.480 was, how do I operationalize, for lack of a better word, this spiritual experience so that other people

00:55:08.080 could experience it as well? That was going on in her mind at the same time that she was

00:55:15.360 interested in her own spiritual development and learned more about Zen and became a student of

00:55:22.940 Zen Buddhism and saw that they connected and came together because ultimately how she translated that

00:55:30.640 personal experience is into this idea that you mentioned earlier of radical acceptance.

00:55:37.280 Can you radically accept this moment, this situation yourself, exactly as it is? And if you can

00:55:47.320 experience that radical and complete and total acceptance, you can experience joy. You can crack

00:55:57.040 open the moment of joy, she would say. There are some things where, like you're stuck in traffic,

00:56:02.400 you're supposed to be going somewhere and let's pretend it's someplace that matters. It's not just like a

00:56:06.580 dinner reservation. Let's say it's your kid's sporting event or you go into the airport and it's

00:56:11.780 a flight and if you miss it, it's going to really wreck things up. And there's nothing you can do

00:56:16.360 about it. You're stuck in traffic, there's an accident a mile ahead, and this is the way it's

00:56:19.480 going to be. Your patient now is in the car and you're sitting with them in the car, understandably

00:56:24.540 getting very flustered at the situation. Walk me through radical acceptance in that situation.

00:56:30.920 How are you helping that person go through the, you know, can you fix this problem? Are you accepting

00:56:36.540 this problem? Going through all of those layers for that specific type of problem?

00:56:41.240 Yes. And I've been in that problem myself, so I understand. Yeah. What I would say as a precursor

00:56:48.780 is that when we're experiencing suffering, however you define that suffering, if you were to look at it

00:56:57.400 more deeply, you would say the vast majority of the time that we're experiencing suffering,

00:57:03.140 it's because we're thinking about something that has already happened, ruminating, wishing it hadn't

00:57:10.700 happened, mulling something over, whatever it might be, or you're thinking about something that may happen

00:57:17.980 in the future. And that actually, if you just experience this one moment and let go of the past and the

00:57:26.640 future, that alone might reduce your suffering a ton. But we could say you might experience pain in

00:57:34.480 this moment because this moment might be painful, but we're not adding on. We're not adding on all of

00:57:40.460 these things that actually increase our suffering. So in this moment, when you are stuck in traffic,

00:57:47.640 you can't undo the decisions that you made that got you to this point. Because of course, we're saying

00:57:57.640 things like, oh, if only I had taken this other road, or if only I had left 15 minutes early, or we 0.99

00:58:03.900 think all these stupid people on the road, if only they had done something different. Those are all 1.00

00:58:10.140 fantasy thoughts because they're all not reality of this moment. So I would say, how do we reduce our

00:58:17.140 suffering in this moment? Is to say, I can't change any of that for today, in this moment. This is

00:58:26.100 what it is. What happens, you'll see, actually, I'm holding my palms up right now as I'm talking,

00:58:32.300 because I associate holding my palms up with this idea of willingly accepting this moment, which is,

00:58:39.340 this is the moment that I'm in. Yeah, it's sort of a surrender posture.

00:58:43.140 Yeah, in a way, it's the surrendering, willing, this is the moment I'm in. And what happens if I

00:58:48.700 just, just, as though it's easy, but what happens if I accept that? Right now, there is nothing I can

00:58:56.360 do to change this. Now, I think the other piece to this is, and this is why it's not just about

00:59:04.260 acceptance, because I would say, if this is something that happens a lot, right, if you often

00:59:10.500 find yourself in situations, whether it's traffic, running late, or something like that,

00:59:16.900 then we absolutely want to figure out how to prevent this from happening as much in the future.

00:59:25.220 But in this moment, when you're there, you can't do that.

00:59:30.760 In other words, in the moment of crisis, you don't really want to be problem solving around,

00:59:36.580 how can I avoid this the next time? How do I avoid this crisis again in the future?

00:59:42.380 When I'm at a 100 or a 90 of distress, I'm not going to be able to effectively do that.

00:59:48.520 Now, obviously, so much of what you're saying sounds very familiar to anybody who has practiced

00:59:54.800 mindfulness or Vipassana or one of its derivatives in forms of meditation.

00:59:59.640 We've had a couple of podcasts that have gone into that. The goal of the practice is to help you

01:00:07.060 identify thoughts and to separate you from these thoughts. There's probably nothing, as you say,

01:00:13.700 in this exact moment that is particularly unbearable, but the thoughts are unbearable

01:00:19.220 if you let them go. I'm going to get to the airport. I'm going to miss my flight. Then I'm

01:00:23.100 going to have to wait for another flight, and I'm probably going to miss that too, or there's not

01:00:25.900 going to be a good seat or whatever. Then I'm going to not get to where I'm going,

01:00:29.020 and maybe the whole trip's canceled. What do you say to the person who says,

01:00:32.960 okay, Shereen, I understand that those thoughts, which are all future, are not happening to me now,

01:00:39.640 and I can just sit here right now in this car. Frankly, I could turn on music and enjoy the music

01:00:44.320 for the moment, but that doesn't change the fact that that's going to happen. It doesn't change

01:00:48.200 the fact that in an hour, I am going to get to the airport. I am going to have missed my flight.

01:00:52.580 What do you say to the person when they acknowledge that I could probably take myself down from 100 to 50

01:00:58.440 by being present in the moment? Will I get back to 100 when I get to the airport, when I realize

01:01:04.440 that I now have to deal with this mess? Possibly, but that's a new moment.

01:01:09.120 Now you're in a new moment and a new situation. Part of it depends on, well, what's your goal?

01:01:14.380 When you're experiencing distress in that moment of being stuck in traffic and not having any control

01:01:21.600 about that, what's your goal? If it's to get to the airport in two minutes, sorry, that's not a

01:01:28.780 realistic goal. We're going to have to let that one go. If it's to problem solve what will happen

01:01:34.440 when you get to the airport, is there something that you can do while you're in the car? Possibly.

01:01:40.420 But if your goal is to, how do I make this moment more bearable because I can't undo anything?

01:01:47.860 Then I think we have some other options available to us, which could be distracting, you know, doing

01:01:54.880 something like music or some other forms of distraction that you could safely do in the

01:02:01.740 context of your car. So now let's look at the other end of the spectrum where I think it becomes

01:02:07.860 even harder to do this. So I'll think of two examples. I think of an individual who receives

01:02:12.120 a terminal diagnosis. They're diagnosed with a cancer, for example, that let's make this even more

01:02:17.720 tragic, right? I think anybody dying of cancer is tragic, but now it's someone your age or my age

01:02:22.160 who's dying decades too soon. But they're basically told, and it's accurate, that look, in six months

01:02:29.620 you're not going to be alive. So in that sense, they're mourning the loss of their life and who

01:02:34.040 they're going to be away from. And then there's another example, which is very fresh in my mind right

01:02:39.640 now because a very close friend of my wife's daughter drowned a year ago. Because we're coming up to the

01:02:45.220 one-year anniversary of that. She's reliving a lot of this. It's hard for me to imagine what

01:02:50.220 she's going through and what her husband is going through, but there's nothing that will undo that.

01:02:56.280 Maybe use those two examples as two of the most difficult examples of how can radical acceptance

01:03:03.340 allow, A, this person who's going to die far too soon to come to grips with that and maybe

01:03:10.060 have a chance at having the best six months that they can have versus not. And then perhaps even

01:03:18.300 more tragically, the parent losing a child, you would sort of hold that up as about as tragic as

01:03:22.800 anything can go, where nothing is ever going to bring that child back. And yes, cognitively you can

01:03:28.540 say, look, you still have other children and you have to be a great parent for them. You can't allow

01:03:32.540 yourself to, like, I don't know how I would cope with that. I don't think I could. I'm not sure.

01:03:36.920 So now let's go from the sort of banal of traffic to the really heavy stuff of life.

01:03:43.540 Easy, right? So I've thought about both of these things a lot or both of these circumstances a lot.

01:03:51.480 One of the misunderstandings about acceptance is somehow this idea that if you accept something,

01:03:59.680 you don't experience pain. And so I want to differentiate that life is full of pain,

01:04:05.500 no matter how zen and mindful you are, you're going to experience pain and a lot of pain.

01:04:12.720 And we're not trying to eradicate pain because actually without pain, and I don't mean physical

01:04:18.300 pain, I mean emotional pain, but it could be both. But without that, we would have other problems.

01:04:24.120 If we did not experience pain as you hear about your friend's daughter, that would be a problem for

01:04:32.800 you in a different way. We need to understand that pain is going to be a part of our lives. And

01:04:38.860 actually, we cause a lot of problems for ourselves when we try to escape the experience of pain.

01:04:44.200 So that's one thing about reality, radical acceptance that I want to talk about. But the

01:04:49.580 other is, when you ask questions like that, like, how can we ask somebody to radically accept this?

01:04:55.620 I would answer in part by saying, what's the alternative? The alternative is refusing to

01:05:03.320 accept. How does that work? How do you do that? And how long can you sustain that for? So I would

01:05:10.260 actually argue that the refusal to accept, or the putting your head in the sand, or the denying reality

01:05:16.960 actually ends up taking a lot more mental resource, and ultimately causing more problems for you in the

01:05:27.320 long run. That said, from a DBT perspective, when we talk about practicing the skill of radical

01:05:33.620 acceptance, we have another expression called turning the mind, which is referring to the fact that

01:05:40.200 practicing radical acceptance involves a very active process of continuously turning your mind

01:05:49.060 towards acceptance. The metaphor is that you're at a fork in the road, and one road is acceptance, and

01:05:54.800 another road is refusal to accept. You're going to come across the fork in the road, possibly multiple

01:06:00.940 times a minute. And what does it look like for you to say, I'm going to actively and willingly choose

01:06:08.300 the road of radical acceptance? How can I turn my mind, my body, my soul towards acceptance? And for me, a lot of

01:06:18.420 it is actually asking myself that question of what's the alternative? What other choices do I have? And

01:06:24.960 recognizing that more suffering comes from refusing to accept more often.

01:06:30.440 The fact that it's referred to as radical acceptance versus acceptance, I think kind of highlights that it's not

01:06:35.380 easy. It's not like you would sit down with my wife's friend, have this discussion once, say, what's the

01:06:40.740 alternative? I know this is awful. But in the long run, this is going to produce more happiness for you and your

01:06:46.580 family. And for her to say, yep, I think that's right. Thanks. No, it's not. It's to your point, every minute of

01:06:55.140 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

01:07:05.060 backsliding. There's a lot of, no, I don't want to accept this today. I don't accept this. I'm angry

01:07:10.080 about this. I want to pout and have a little pity party about this. And then maybe I experienced that

01:07:14.760 and I realized that wasn't very productive because now I feel actually worse. You know, we were introduced

01:07:20.160 through Andy White, which is who I work with. And I just think the world of Andy. One of the things

01:07:24.280 about DBT that for me makes it a wonderful system is that you do work. You write, you have

01:07:30.200 homework. You have to write out your emotions and your decisions and the trees. If you feel this,

01:07:37.100 do you do this? And how deliberate was that in Marsha's mind as a system? I've never done CBT,

01:07:42.920 so I don't know if CBT has a similar workbook and she's just modifying it. Is that something that's

01:07:47.420 been modified from other systems? Certainly CBT is associated with doing homework, doing work in

01:07:54.680 between sessions. More standard cognitive therapy is associated with doing worksheets about your

01:08:02.060 thoughts, what thoughts you have, what the evidence for your thoughts are, that sort of thing.

01:08:07.240 Doing work, doing worksheets, not shying away from the term homework as part of the treatment

01:08:13.760 is very consistent with the CBT model. What I will say is, you just reminded me about this based on

01:08:22.180 something you said, is that one of the assumptions about borderline personality disorder from the DBT

01:08:29.440 lens is that we use a skills deficit model, which is to say that we believe that people who end up

01:08:37.560 with the constellation of problems associated with borderline personality disorder have an absence

01:08:42.460 of certain skills and skillful behavior in their lives. And that absence could be a result of never

01:08:50.420 having been taught it in the first place or having had effective behaviors, been punished out of them

01:08:57.340 by their environment. This is the environmental piece that we're talking about, but they don't

01:09:01.820 have, we all have certain deficits in some skillful areas. And another one I would just add to that is

01:09:09.120 the skills have never been modeled for you. You've done them correctly and been punished for them.

01:09:13.560 I think a bigger one might be, you've done them incorrectly and never been corrected.

01:09:19.260 Yeah, that's a good one too.

01:09:20.480 So you built all the muscle memory doing it wrong your whole life and you didn't have parents there

01:09:25.580 to say, hey, that's not how you do it. Do it this way.

01:09:29.060 And it's a lot harder to unlearn a behavior than it is to learn a new behavior. We know that as a

01:09:36.160 phenomenon. Marcia developed this book we refer to as the skills training manual. That's part of 0.99

01:09:42.700 the treatment of DBT. And perhaps what DBT is probably most known for, more broadly speaking,

01:09:49.820 are the skills that are part of it. But that these skills deficits are thought to exist in

01:09:56.200 four different domains or five different domains, actually. Mindfulness. So when we say someone has

01:10:01.740 a deficit in mindfulness, it's not that we're referring to anybody who doesn't practice Zen as

01:10:06.660 having a mindfulness deficit, but it's a deficit in the capacity to be aware of the present moment.

01:10:12.700 Basically. Another domain in which people have deficits is interpersonal effectiveness.

01:10:19.660 As I go through this, you'll see everybody has deficits in all of these areas at different times.

01:10:24.820 And I think, again, that's part of the beauty of DBT is that it can help so many people. So

01:10:28.800 interpersonal effectiveness, which could mean conflict with others, but also could mean deficits

01:10:33.860 in knowing how to ask for something effectively, how to say no effectively. Emotion regulation

01:10:39.940 deficits is the third domain. Deficits in knowing how to label your emotions, what to do with emotions

01:10:47.000 when you have them, how to prevent having intense and extreme emotions, how to change emotions. Can't

01:10:53.260 remember if I said that. And then a fourth domain is deficits in distress tolerance. How do you tolerate

01:10:59.880 really stressful and distressing situations without doing anything to make the situation worse?

01:11:05.340 And then the fifth area that is not talked about as much, though I can certainly talk about it if

01:11:11.320 that'd be helpful, is this idea of self-management, deficits in self-management, which has to do with

01:11:16.780 being able to do things you don't want to do. Broadly speaking, how some people can get up every

01:11:24.600 morning at six o'clock and go exercise and eat a healthy breakfast and go to work while other people

01:11:31.360 snooze their alarm eight to 12 times, haphazardly eat breakfast sometimes, get to work late. You know,

01:11:40.520 those are sorts of things that we might say fall into this kind of self-management domain. And so

01:11:46.280 DBT is designed as a treatment package to teach people the skills to overcome deficits in these

01:11:54.220 different domains.

01:11:56.340 I actually wasn't aware of the fifth. I was really only aware of the four. Is that fifth one

01:12:01.080 kind of a more recent addition?

01:12:03.760 No, it's actually in the original treatment manual in the 1993 text that she put out. But

01:12:10.300 her thinking was, I don't need to create a whole other skills module for self-management

01:12:14.840 because DBT therapists are going to infuse this throughout their entire treatment. And I think

01:12:21.180 this might've been at the time, a little bit of a missed opportunity because I don't think she

01:12:25.620 realized that actually a lot of clinicians don't know how to do that very well. Marsha was thinking

01:12:32.000 that actually this is where behaviorism comes in. It's teaching people principles of behaviorism.

01:12:37.560 So you don't see it in the original skills manual and you don't necessarily see it in the new skills

01:12:43.760 manual or what I refer to as the new skills manual, unless you look, because where you would see it now

01:12:49.360 is in the set of skills that are referred to as the walking the middle path skills, which actually came

01:12:55.200 out of the first adaptation of DBT for adolescents and their families. And Jill Rathis and Alec Miller,

01:13:04.040 who along with Marsha created the adolescent version of DBT, took a lot of these principles of the

01:13:11.200 self-management skills and created this fifth module of DBT skills called walking the middle path,

01:13:17.940 which they teach adolescents and their caregivers, their parents, these skills about how to manage

01:13:25.160 your behaviors, how to learn behaviors and to be more effective more broadly.

01:13:30.460 Just going back to the origin of DBT around a modified tool to help some of the people who are

01:13:39.660 suffering the absolute most. You think somewhere in the back of Marsha's mind, it probably wasn't just

01:13:44.660 how do I make CBT better to handle the most recalcitrant depression, suicidal patients.

01:13:52.520 Perhaps on some level, it was also BPD. We kind of glossed over this, but I'm guessing that CBT

01:13:57.840 has historically not been very successful for borderline personality disorder. Is that a fair

01:14:02.480 statement? Well, I would say at the time that Marsha was doing this treatment development, we didn't know

01:14:09.440 the general thought. And there actually, there have been more studies that have looked at whether

01:14:16.800 the presence of borderline personality disorder interfered with outcomes for standard CBT. And there's kind

01:14:24.100 of mixed data on that in that some studies show that the presence of BPD did lead to worse outcomes in

01:14:31.980 some studies. But what I was going to say is that Marsha didn't know. The reason that she gives for

01:14:39.320 her pivot to borderline personality disorder as a population of interest is that when she was first

01:14:47.260 seeking research dollars, research grants to study the development of DBT and, you know, to start to do

01:14:56.260 randomized clinical trials of DBT, rather, back in those days, you could only get research grants from

01:15:03.920 NIH if you identified a disorder of interest. The way she tells it as oversimplified is that she was

01:15:11.340 interested in suicide and suicidal behaviors. And at the time, she thought her choices based on that

01:15:18.200 behavior was either depression or BPD. And she said at the time, she didn't want to do

01:15:25.980 depression because there were already so many smart people doing depression research. She wanted 0.93

01:15:31.480 to go into an area where there weren't already a lot of people doing research in this area. And

01:15:36.460 that's why she chose BPD. Again, this is the story. But of course, I think there's more to it than that

01:15:41.480 because her own experiences would lead one to assume that she also had specific interest in the

01:15:48.920 emotion dysregulation piece that goes along with BPD and doesn't necessarily go along with more

01:15:55.400 standard depression. So what would you say? I know what I would say, but what would you say to

01:16:00.240 somebody who doesn't have BPD, is not depressed, who says, you know, Peter, Shereen, this is all very

01:16:06.380 interesting, but would there ever be any benefit in me doing DBT, given that this program was really

01:16:13.900 built around people with real pathology, of which I have none? I went through the DSM-5 last week.

01:16:20.360 I don't meet the criteria for anything fully. Would there be any value to me in this type of

01:16:25.500 practice? I think that's part of what's so fascinating about this treatment because you're

01:16:30.240 exactly right. This was the treatment that was developed for what could have been termed the

01:16:35.140 worst of the worst at the time. And it's a treatment that is actually for all of us. I have yet to meet a

01:16:43.260 person who could not benefit from at least learning some of the skills. I've yet to meet a person who

01:16:50.780 hasn't identified the skills as being something that could be relevant for them. Now, whether they're

01:16:56.960 always willing to use them or apply them or want to do them, that's a different issue. But when I talk

01:17:02.300 about here's what the skills are for, I get universal agreement that those skills could be useful to learn.

01:17:12.340 You don't know this about me, but I love cars and race cars and all sorts of things like that.

01:17:16.960 And a lot of people say, I don't really understand how there's any value in a company like Mercedes or

01:17:23.500 any of these companies participating in building race cars. It's such an expensive proposition. It

01:17:29.020 seems so gratuitous. But the trickle-down effect for what the impact of that is on street cars is

01:17:36.600 remarkable in terms of fuel efficiency, power, safety, all of these things. It's true. If you want to

01:17:42.100 build a Formula One car, it's basically a $400 million a year operation to build and operate

01:17:46.680 those things. But those things are functioning at the absolute limit where every gram matters and

01:17:53.300 the stakes are so high. And if you take everything that you learn there and bring it down to the rest

01:17:59.400 of us who aren't driving Formula One cars, the benefit is actually enormous. And I think of it as sort of

01:18:04.800 similar, right, which is this is a system that was conceived and validated on a sample set of people

01:18:13.080 with real difficulties in regulating their emotions. You know, when I go through the list of the DBT

01:18:19.320 skills pillars, it's like check, check, check, check, check. I might not meet the diagnostic criteria

01:18:24.260 for something in the DSM-5, but I have enormous problems with all of these things. I have staggering

01:18:29.120 deficits of skills. I mean, one of the first exercises that really illustrated that was

01:18:34.380 something as simple as identification of emotion. You know, it was any emotion that-

01:18:40.120 I wouldn't say that that's simple necessarily, but yes.

01:18:42.800 Yeah, yeah, yeah. But it was like, I couldn't really identify an emotion that wasn't anger. It was very

01:18:48.200 difficult to go beyond anger to helplessness, sadness, hurt, fear, all of these other things.

01:18:55.120 Andy and I must've spent three months with my homework just being, okay, you're going to get

01:19:00.480 angry 16 times a day, 16 times a day, pull out this sheet and go through and figure out what else

01:19:06.620 is going on. That sounds maybe simple, but that's learning a new language as well.

01:19:12.500 What made you want to do that? Why not just stick with your experience of anger?

01:19:16.820 It's exactly what you said earlier. It's like, what's the alternative? Well,

01:19:19.500 the alternative is you're really alienating a lot of people. And I think watching my kids get older

01:19:26.380 and realizing I don't want them to see me, you know, I think I was just angry 24 seven. I don't

01:19:32.800 think I really experienced anything that wasn't anger. So it was just saying like, I have to sort

01:19:38.840 of break this cycle because if every time I get cut off on the road, I'm screaming so much at the

01:19:44.900 person who cut me off that you can see the droplets of my spit on the windshield. Even if

01:19:49.500 I'm not yelling at them, it's not like I was actually yelling at my kids. As I've learned since,

01:19:53.660 I don't think kids can appreciate the difference. A five-year-old doesn't understand that just because

01:19:59.620 daddy is yelling at the guy that cut him off, he's not mad at me. So I think once I came to realize

01:20:05.120 that, I realized, no, I don't want to do this.

01:20:07.540 So I don't actually have my own experiences with borderline personality disorder or psychopathology

01:20:15.740 in that way. And I learned DBT as a grad student in my early twenties. And it's been a long time now

01:20:27.020 that I've been using and applying DBT. And I will still go in my head, like when I have a difficult

01:20:33.100 interpersonal situation happening, where I will walk through the steps in my mind of the dear man

01:20:39.440 skill of how to ask for something and be effective. Let's go through dear man in a moment, finish your

01:20:44.160 story, but I would love to go through it. It's been 25 years and I'll still be writing an email

01:20:48.780 and then I'll say, wait, pause, edit. Am I following the DEAR structure? What can I take out? What am I

01:20:56.140 adding on? What judgments are in here? So I feel like, you know, I've been a pretty skillful person for

01:21:02.120 most of my life and I still benefit from actively thinking about using these skills in my daily

01:21:10.000 life. I'm still so early in my journey. I would say I'm if 10 out of 10 is having all the skills and

01:21:16.820 always employing them. One out of 10 is not even knowing what a skill is. I'm in the sort of three to

01:21:23.440 four out of 10 range, which is I know them and half the time I reach for them correctly. But let's talk

01:21:30.000 about dear man because everything in DBT is really built around being highly accessible. It's not

01:21:35.940 really, at least to me, it doesn't come across as having errors. It's funny acronyms. It's like

01:21:41.720 little diagrams. There's nobody that can't do this. So tell everybody what dear man is and what the

01:21:47.780 acronym is really used to walk you through as a thought process. I think sometimes people actually

01:21:53.140 have a negative reaction to all the acronyms in DBT. And I think that's a fair criticism, but acronyms are

01:21:59.000 meant as mnemonics to help us remember things. Maybe because I went to medical school, we just

01:22:04.940 you're used to do so much through that. Yeah, yeah, yeah. Yeah, though, I will say I was training

01:22:08.880 DBT somewhere. Where was it? I think it was Iceland, where they don't do acronyms. Like it's just not

01:22:14.440 part of their language to use acronyms. And so that is an added difficulty. But in the US and Canada,

01:22:21.360 we can talk about these acronyms. So dear man is a skill that's in the interpersonal effectiveness

01:22:28.520 module. So these are the skills that are designed to help you be more effective with other people in

01:22:34.160 your life. And dear man is specifically the skill on how to ask for something in a way that gets

01:22:41.380 another person to give it to you, or how to say no to something in a way that gets the other person

01:22:48.460 to accept your no, or increases the likelihood, I should say, because nothing is going to be 100%

01:22:53.600 effective. So dear man walks you through these seven sub skills to help you do that. It stands

01:23:02.380 for describe, express, assert, reinforce. That's the D-E-A-R part. That's basically what you say or 0.51

01:23:12.780 write to ask for something. And then the man stands for mindful, appear confident, and negotiate or be

01:23:21.340 willing to negotiate. So that when you're in a situation, so I don't know, do you have a situation

01:23:27.240 that is coming up for you where you need to ask for something or say no to something?

01:23:32.060 Yeah, I do actually. I don't think I can talk about it publicly, unfortunately. It's a very good

01:23:37.520 one, but I probably can't talk about it publicly. Let me think of one where I could without embarrassing

01:23:42.260 someone. Okay, this is going to embarrass the hell out of her, but let's try it. My daughter wants 1.00

01:23:47.220 to get a third earring. So she's got two piercings in her ears, and she really wants to now get a 1.00

01:23:52.400 third. Maybe this isn't a great example, but I'm hoping to talk her out of it for a little longer.

01:23:57.120 How's that? I'm like, why don't you wait till you're a little bit older? I just have this fear

01:24:02.000 that she's going to damage her ears and have so many things hanging that it will stretch her ear

01:24:06.720 lobes out, and she'll be 50 years old like me one day and regret it. Potentially a totally 1.00

01:24:11.680 irrational fear, but that's the fear I have. So the ask that you want to say is,

01:24:17.700 will you postpone this decision for a while, or will you take this off the table for a period of

01:24:23.800 time? Someone listening to this might say, what kind of lousy parent are you? Just assert it. 0.96

01:24:28.380 But her mom is not opposed to it. Her mom's like, I think it's reasonable for her to get it. So now

01:24:32.840 it's become more of a negotiation. And how old is she? She's 13. So if you were to practice the

01:24:39.100 dear man, the first step would be to describe the situation without adding on any interpretations

01:24:44.540 or judgment. If I were your daughter, you would say to me, Olivia, I understand that you want to now

01:24:52.000 get a third hearing. Great. So often this means exactly what you did, which is to keep it short,

01:24:59.000 because sometimes we have a tendency to go on and on and on about all of our reasons for something.

01:25:03.880 But actually, the more we do that, the more we lose the other person's interest.

01:25:08.300 And then express would be to express your feelings about it.

01:25:12.980 I have some fear about you getting a third earring, because I worry that it would damage your ears.

01:25:20.180 And this would be something that would bother you many years from now.

01:25:24.340 We could work on simplifying or shortening or saying, I fears that you would regret this if you

01:25:30.560 did it, whatever it might be to get the express. But that was also really nice because you didn't add

01:25:36.080 on judgments. You didn't say you shouldn't do this, right? These are all just describe the facts

01:25:41.980 and then express your feelings about it. Now, assert is where you ask for, that's the A, where you ask

01:25:47.900 for directly what it is that you want.

01:25:50.540 Olivia, would you be fine if we could postpone this decision until you're older, maybe even out of high

01:25:58.420 school? So you may think about prior to doing it, what is it specifically that you're asking for?

01:26:06.640 So if you want to start out by asking, would you be willing to postpone this decision until after high

01:26:12.700 school? Might be a more direct assert, but it could be there's other factors that might contribute to

01:26:18.700 you asking it more tentatively or more firmly. Now, what we often say about this, you didn't illustrate

01:26:25.700 this, but what we often say about this A part, the assert, is that a lot of the time we don't

01:26:31.960 actually assert. We just want somebody else to read our minds or do what we want. And I think this is

01:26:39.200 especially a problem for not to overgeneralize, but I think women have more trouble with this 1.00

01:26:45.040 on average than men. Loads of reasons for that. But actually asking directly for what it is that you 0.50

01:26:51.780 want is really challenging for people. And so what instead you would see people doing is just doing

01:26:57.360 the describe and express and then expecting the other person to just know what it is they want and

01:27:03.520 do it. So we're trying to get people to learn how to be more comfortable with asking and stating

01:27:09.560 directly what it is that you want. And then the R stands for reinforce, which is to say, you want to

01:27:17.960 say explicitly what's in it for the other person, what reward could come their way by giving into

01:27:25.060 your request or giving you what you want, which in a second, we can talk about whether or not this

01:27:30.440 is manipulation. But in the moment, in your dialogue with Olivia, what's something that you

01:27:35.800 could imagine reinforcing? You play volleyball. You're really good at volleyball. You're playing

01:27:41.780 year round now. And the more jewelry you have on, the greater your risk of injury. You get hit in

01:27:47.980 the head with a ball. That's one more thing that could hurt. This is just one less thing to worry

01:27:53.440 about, right? That would be one sort of very narrow niche approach. Probably my preferred way would be

01:27:57.820 something like optionality is a great thing. And by not doing it now, it doesn't mean that you can't do

01:28:05.800 it tomorrow. You always have that option, but you can't undo it once you have it. Now she'll argue,

01:28:11.680 yes, you can. You can just take it out. So I don't know, maybe she's right. But those would be the

01:28:15.320 things I would reinforce, which is, I'm not saying no, I'm just saying not now. And that really isn't

01:28:21.580 taking anything away. It's just potentially delaying something. I agree with you about all of those

01:28:26.400 points. What you're doing is you're providing more evidence in favor of what it is that you're

01:28:32.200 asking for. But if I were to think about reinforcing in the sense of what reward could she expect if she

01:28:42.040 were to say, yes, dad, I won't get another piercing. Could you think about something?

01:28:49.520 So is this something where I could literally just say, and if you don't do this,

01:28:53.980 is it literally like you're bribing your kid? Is that potentially what's in there?

01:28:57.840 It would be bribery, but bribery is what we do all the time.

01:29:01.000 Would it be something like, and if you don't do this, we could go shopping in those new

01:29:06.160 Converse shoes you love. Let's get those instead.

01:29:09.340 It could be.

01:29:10.320 Okay. I never thought of it that way. I've always thought of it in more theoretical reinforcement.

01:29:15.280 Which I think can work sometimes with some people. More often than not, it needs to be a tangible

01:29:22.660 connection to this. Now, what we often say is a good fallback to asking somebody for something

01:29:28.640 at work or interpersonally is to say, if you do this, I would really appreciate it.

01:29:33.500 My appreciation of you and your behavior is a reinforcer. You might feel good by the fact that

01:29:39.540 I appreciate it. When I see something like what you're describing your daughter wants,

01:29:44.040 her dad's appreciation of-

01:29:45.800 Not high on the list of things she-

01:29:47.600 Exactly. Right? So you have to think about the person that you're asking and what is most likely

01:29:53.420 to work. You also have to think about, to a certain extent, how important is it for you to get this

01:29:58.620 thing that you're asking for? And if it's really important for you to get it, then you might say,

01:30:03.260 oh, I don't like buying her sneakers instead. But if that's what worked, then we would say,

01:30:07.940 you know, be effective in this situation if this was something that was really important to you.

01:30:12.860 There's a meta thing here, which is I'm teaching her by my behavior and my interaction what is a

01:30:22.100 more emotionally regulated way to handle this. Because the old version of me would have just

01:30:27.540 said, no, I'm the parent. You're doing what I say. This is non-negotiable. And if I was a kid and

01:30:33.300 argued this, I would have got the back of the hand to my face. So just be lucky you're not getting that

01:30:37.360 for even pushing and provoking this discussion. You know what I mean? So that would have been the

01:30:42.440 old way to have dealt with this. And then she would have run out and gotten the earring and just 0.83

01:30:46.820 tried to hide it from you. Right. So now instead we get to model something better. And I assume that

01:30:53.820 that also factors into the DBT for adolescents, which I actually haven't really spent any time looking at

01:30:59.360 that work. But I would imagine that it's as much about helping the kids as showing the kids how the

01:31:05.880 parents can change as well. So in standard DBT for adults, what we do, we haven't really explained

01:31:12.740 what the therapy looks like. But in general, what would happen if somebody were receiving DBT treatment

01:31:17.720 is that they would be coming to a skills training group once a week or receiving skills training

01:31:24.100 individually, where they meet with a therapist who teaches them these specific skills. They practice

01:31:29.720 it. They come back, report on their practice and get feedback and coaching, et cetera.

01:31:34.840 In skills training group, you might have a number of adults all together and you teach them all

01:31:41.060 together and you assign homework and you all talk about the practice and use of skills.

01:31:45.740 What was an amazing, just think it's so brilliant adaptation for DBT for adolescents is that in your

01:31:52.980 skills group, you have, they're called multifamily skills groups where you have the adolescents in the

01:31:58.500 skills groups, but you also have the adolescents parents or caretakers in the skills group at the

01:32:05.040 same time. And everybody is learning the skills all together. And the way these groups are designed,

01:32:11.600 it's not, oh, we're all learning these skills so that you all can help your adolescent apply them.

01:32:17.720 Of course, that's part of it. But we're framing the groups as saying, we're teaching everybody the

01:32:23.080 skills because the parents need the skills as much as the adolescents need the skills. And therefore,

01:32:28.200 the parents and caregivers have to practice the skills on themselves, not just for their

01:32:34.420 adolescents. Do you find it's harder for the parents? Because, you know, you said something

01:32:38.500 earlier, which I completely agree with. It would almost be easier to come to DBT with no skills,

01:32:44.140 positive or negative, and then just learn the positive skills. It's harder to come in when you have

01:32:49.720 decades of reinforced negative skills, anti-skills. And you have to unlearn anti-skills and then build

01:32:58.660 positive skills. So do you see that it's easier for the kids sometimes to pick this up than their

01:33:03.460 parents? Sometimes easier to pick up, but there's different levels of willingness and willfulness.

01:33:09.940 Yeah, fair point. So with adolescents, a lot of the times adolescents-

01:33:13.760 They're not necessarily there by choice, I'm guessing sometimes.

01:33:16.060 Yes. So a lot of the times it's their parents or their schools that say they have to do this. And

01:33:21.580 so there's always a question of how much they're there because they want to be there. Of course,

01:33:26.820 with adults in certain contexts and situations, they don't want to be there either, but there's

01:33:31.960 generally more willingness. Let's talk about the structure of the therapy. I've jumped around a lot

01:33:37.080 because there's just so many interesting frameworks and I want to make sure we get to them. But

01:33:40.120 let's assume that a person comes to you now and they're there by their own choice. This is an adult

01:33:45.780 and they don't meet the criteria for any of the DSM-5s. So this is just someone who's having

01:33:49.800 difficulty interpersonally. One of the things that I think I sort of realized was so much

01:33:54.920 dysregulation stems from interpersonal interactions gone bad with your spouse, with your child, with your

01:34:01.740 coworker, with the person who cuts you off on the street. I mean, it's generally an interpersonal

01:34:06.920 interaction that doesn't meet your expectations, whether those are reasonable or not reasonable,

01:34:13.420 that then leads to sort of an emotional regulation or dysregulation, thoughts that then feed into

01:34:20.440 those emotional dysregulations. And then you create this awful feed forward loop that can lead to bad

01:34:27.180 behaviors from interpersonal to thoughts, emotions, thoughts feeding off each other and then behaviors.

01:34:32.560 I mean, that's kind of like the pathway of how this all seems to go wrong for people. There are some

01:34:37.600 people out there who seem just wonderful and they don't seem to suffer from these issues. But most people,

01:34:42.680 if we're being really honest with ourselves, even if you're not as extreme as me, I think most people

01:34:47.420 realize that this isn't always going well, especially as we're under more external stress.

01:34:52.220 I love the idea of distress tolerance. I think that's just one of the most interesting concepts

01:34:56.720 is a window. And that's the sort of image that I have of it. This entire year, my distress tolerance

01:35:02.480 window is about this thick and it's all my own fault. I've put way too many things on my plate.

01:35:07.980 And so there's no buffer. There's no margin for error. Even before this podcast was recorded,

01:35:13.260 I was getting upset about some stupid video I had to record. I had to record it twice. It was supposed 0.98

01:35:18.420 to be two minutes. The first time I did it, it took two minutes and 20 seconds. Like something so dumb

01:35:22.760 that shouldn't even bother me bothered me because I'm out of time. So something like external factors 0.95

01:35:28.680 will change your distress tolerance window. For me, it's always being too close to the top where it's

01:35:34.480 getting upset. But for some people, it's being too close to the bottom and it's getting sort of

01:35:38.800 dysthymic or depressive versus getting irritable. During good times, imagine being on vacation for two

01:35:45.760 weeks. You don't have to worry about email. Nothing is going on. You go to a restaurant and they forgot

01:35:50.960 your reservation. You're like, yeah, no problem. We'll go to the next one. I think people can resonate

01:35:54.780 with this idea. One of the skills is how do you make that distress tolerance window higher? How do you

01:36:01.060 make it wider? There's nobody that's not going to benefit from this. It's a long rambling question,

01:36:05.580 but really where I'm going is you get somebody that comes in. Where do you start? When you just said

01:36:10.760 that, what I was reminded of is learning what makes us more vulnerable to negative emotions or stress or

01:36:18.360 distress. And that is another key skill in DBT is to identify and understand what our vulnerability

01:36:27.020 factors are and then to address. Because sometimes we could actually target or treat our vulnerability

01:36:32.560 factors and our lives just go much more smoothly when we sleep decently, when we remove some things

01:36:42.300 from our list so that we're not so stressed all the time. That could actually solve a number of problems.

01:36:47.540 I'm glad you brought that up because I should have mentioned that's actually one of the first things

01:36:51.520 Andy asks me. I've been working with him for two years now. It's always once a week. But that's one of

01:36:56.280 the first questions he always asks, which is, tell me what's going on physically. Are you in pain?

01:37:01.920 Are you sleeping? What are the other vulnerabilities? And I think out of the gate, he's trying to gauge

01:37:07.680 what state I'm in as a function of how many things are pressing me.

01:37:13.440 And how in those moments, how able are you to receive info? Like if you're at 90 on a scale of 0 to 100,

01:37:21.580 you're not taking in a lot. You're not learning a lot. If you're at that level, then we need to figure

01:37:28.160 out how do we get you regulated enough so that you could learn to do something differently. And I think

01:37:35.200 that that's great that he asked those questions. I think for myself, when I'm in physical pain,

01:37:40.220 I just can't do much of anything.

01:37:43.220 He's had me pay much more attention to those things. If you haven't slept well in two nights,

01:37:48.960 you can't and you shouldn't assume that you're at your best in terms of your ability to receive

01:37:55.480 both information and tolerate things. Physical pain is a very interesting one. I agree with you

01:38:01.200 completely. I'd love for you to share an example of your own life. I have so many of where I've been

01:38:06.360 in pain and it's made me more irritable. What have you noticed and what do you do about it specifically?

01:38:11.640 I just admire people so much who have chronic pain conditions and function in their lives because I

01:38:18.820 have been fortunate to not, I mean, I've had pain, but to not have a chronic pain condition because I

01:38:25.340 think that would be a challenge for me to learn how to navigate that. But I do think that when I'm

01:38:32.280 experiencing pain and whether it's a transient headache that I know will pass or I hurt my back,

01:38:41.900 you know, exercising and now I feel it every which way. I personally recognize that as a huge

01:38:48.220 vulnerability factor for me because it makes me more irritable in general and makes me much more

01:38:56.380 likely to snap at people or to have less patience for things. So for me, what that means is recognizing

01:39:04.560 similar to what you said, like, okay, this is going on for me right now. I have to accept this is going

01:39:11.400 on for me right now because I can't just will away physical pain as much as I want to and know that this

01:39:17.980 is a vulnerable time for me. So given that it's a vulnerable time for me, is there a way that I can

01:39:23.740 reduce demands on myself in other ways? Or is there a way that I can treat myself kindly in other ways

01:39:32.220 to kind of offset the pain that I'm experiencing? And sometimes for me, it's also learning to be more

01:39:39.780 explicit and vocal as it relates to kind of this interpersonal effectiveness. Because when we

01:39:46.100 experience pain, it's often entirely experienced within our bodies. Other people may not

01:39:53.700 even know that this is happening for us. So learning to say out loud, and granted, it helps as your

01:39:59.580 kids get older, you can say things when they're younger, you can't say as easily, mommy has a

01:40:04.700 headache. But they get older, and you could say, I'm really suffering right now from this headache. So I

01:40:09.940 need to have a little bit of space from this conversation or this situation. So learning to recognize this

01:40:16.400 as a vulnerability factor, and then figuring out how can I act more skillfully within this context to

01:40:22.680 prevent the lashing out to prevent irritability. Because I don't know if this is your experience,

01:40:29.300 Peter, but mine is that whenever I do act out of anger, I almost always regret it, and almost always

01:40:37.000 feel worse about myself afterwards. And so it's almost a selfish process. It's to help the other person by

01:40:44.740 saying, I'm not going to get irritable with my kids. It's to protect them. But it's also to help me

01:40:49.280 not feel so bad afterwards, because my kids will recover, I'll recover, but I don't like how it makes

01:40:55.320 me feel.

01:40:56.220 The cycle of anger and shame, and isolation, I know the path well.

01:41:00.960 Yeah.

01:41:01.760 Before we leave the pain thing, one thing I've observed in myself is not all pain is created equal.

01:41:07.380 Expected pain seems to be far less destabilizing to me than unexpected pain. I had shoulder surgery

01:41:12.760 recently. I don't know why I hadn't been told how much it would hurt. So I didn't really want to take any of the

01:41:18.260 narcotics and things like that. For two days, the pain was so bad I couldn't sleep. I mean,

01:41:21.600 literally, I was just sitting up in a chair and not sleeping for two nights. But even for that week,

01:41:25.660 the pain was excruciating. Interestingly, it didn't negatively impact me in terms of

01:41:32.080 interactions. Knowing what I know about how much pain can destabilize distress tolerance capacity,

01:41:38.360 I would have thought, well, that would have thrown me over the edge. But it didn't, because it was

01:41:42.020 like, look, I had six trocars in my shoulder. I just had an enormous operation. This is kind of

01:41:48.280 what it's going to feel like. Whereas I've had headaches that have lasted for three days at a time

01:41:54.240 due to some awful tension, and no amount of Tylenol can make it go away. Ostensibly,

01:41:59.880 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.

01:42:05.220 I find that far more destabilizing to me from an emotional regulation standpoint. I don't know if

01:42:10.800 you've ever observed that. And by the way, I think people with chronic pain, that must be the most

01:42:15.140 frustrating and difficult thing. Because a lot of those patients are told by physicians,

01:42:20.020 either A, there's nothing we can do, or B, this is in your head. And really, you should just kind of

01:42:24.240 ignore this. I 100% agree with you personally and professionally. What I noticed in what you said is

01:42:31.160 that you actually engage in a lot of self-validation with regard to the shoulder surgery,

01:42:37.420 basically saying, of course, I feel this way. It's okay to feel this way. And I think with the

01:42:42.980 other pain that we experience, sometimes we might not realize that we're doing this so explicitly,

01:42:48.480 but we're actually invalidating ourselves. We're saying, why am I feeling this way? What's wrong with

01:42:54.120 me? How could this be happening? And so we're rejecting it. And I have my own personal example. I'm

01:42:59.620 tapering off a medication right now. And I didn't realize when I was prescribed this medication,

01:43:06.460 how difficult it's known to be a medication that's difficult to get off. And had I known that,

01:43:13.020 it was sort of a moment of weakness that I was prescribed this, I decided to take it.

01:43:17.840 Had I known how horrible it would feel to go off it, I never would have gone on it.

01:43:21.980 But now I'm trying to wean myself off of it. I'm really going kind of nuts with how much I'm like

01:43:28.540 micro-dosing myself on this medication, because I start to feel this withdrawal symptom. And I'm

01:43:35.480 realizing exactly to this point that you made is that part of the suffering that I'm experiencing

01:43:40.860 about this is my thoughts like, oh, what if this goes on forever? What if this doesn't end? And even

01:43:49.100 when I realized, okay, it's not going to last forever, the subsequent thought is, but can I

01:43:53.380 tolerate this for two weeks? Why can't it just go away? And so this is the way in which we do have

01:44:00.420 some control over the suffering that we experience, because we're adding on all of these thoughts.

01:44:07.260 One of the mindfulness tricks that I really love when I hear it, I think I heard it as it relates

01:44:13.020 to like learning to be mindful and accepting of your emotions, is just to say to yourself,

01:44:18.980 it's okay to feel this. And it seems so simple, but to say those words, it's okay to feel this,

01:44:26.000 no matter what the this is, can be a really powerful experience. And I think even with the

01:44:31.940 pain, we could say it's okay to feel this and just notice what effect that has on us.

01:44:39.860 So going back to the beginning of the interaction with the clinician and the patient,

01:44:44.360 you start with this idea of what are the vulnerabilities. So once you establish that,

01:44:49.860 and I suspect a lot of that is you'll see it quicker than the patient will. Like a lot of times

01:44:55.320 people probably don't appreciate what the vulnerabilities are until they're kind of pointed

01:45:00.640 out, which is no, like these are, again, it's a form of validation. These are really clear things

01:45:07.020 that are going to make it more challenging for you to be understanding of others, to be understanding

01:45:13.440 of yourself, to regulate your emotion, to control your thoughts, and ultimately to control your

01:45:17.700 behaviors. So once you establish that, I imagine it's somewhat liberating for people. It's a nice

01:45:23.720 first way to have you validate things for them. Is that usually received that way?

01:45:29.720 Yes. I think for a lot of people, understanding the vulnerability factors and determining ways to

01:45:37.640 reduce their vulnerability is really critical. And you asked me like what I would typically do with

01:45:44.580 somebody who first came in. I mean, I'm used to working only with people who meet criteria for BPD and

01:45:51.380 are usually on that more severe end of the continuum. I don't have experience with people that are not as

01:45:58.880 extreme. Usually, I think that for a lot of people learning about vulnerability factors is really

01:46:04.600 important, but I put vulnerability factors in the context of something that we do in DBT called

01:46:09.680 chain analysis, which is a way of assessing problem behaviors that people have that they want to

01:46:16.040 change as a way of assessing it in order to figure out how to change it going forward. So vulnerability

01:46:22.280 factors is an element of that chain analysis. So say, for example, you were in treatment with me and one of

01:46:30.240 the things we were working on as this target behavior of you exploding in anger at various

01:46:36.540 points, we would identify a recent occasion in which that happened. And then we would do an

01:46:42.780 assessment of what were all the factors, events, thoughts, behaviors that led up to that behavior.

01:46:48.720 And then what were the consequences of that behavior? That would be the chain that we assess

01:46:53.440 as a way of identifying, okay, well, what can we modify in this chain going forward to make it less

01:47:01.180 likely that that problem behavior is going to show up again? And I think what we've been talking about

01:47:06.820 is addressing what happens actually very early on in the chain, that vulnerability factor. And for

01:47:12.560 some people, and in some situations, working on the vulnerability factor changes everything that

01:47:18.400 follows. But there's other events and circumstances where it's not about the vulnerability factor or

01:47:24.760 the vulnerability factor is just one element, but something happens in the environment, a prompting

01:47:29.540 event, we would call it, perhaps that sets off the chain. And it doesn't matter whether you got sleep

01:47:35.640 or not the night before, because whenever that prompting event happens, you're going to explode in

01:47:41.060 anger, right? So we want to work on vulnerability factors, but we also want to identify, well, what are some

01:47:46.320 other critical elements along the path towards the problem behavior that we can address and

01:47:54.560 behaviorally manipulate? When you say that that way, it's really obvious because even using myself

01:48:00.220 as an example, which is probably a more extreme example, nothing ever occurs in isolation. Like I've

01:48:05.860 yet to come up with one example in my life where I can say I flew off the handle and it was only because

01:48:11.360 of what was happening in that moment. I mean, it's just not the case. If I flew off the handle,

01:48:16.180 this is a situation where I would have barely got upset a day ago or a week from now. It was that

01:48:21.700 literally the six things that had happened, and maybe I didn't have a great sleep. That's not what

01:48:25.660 caused it, of course, but that made me more susceptible. And maybe this other thing happened

01:48:30.220 and I didn't deal with it. I didn't confront the person who said such a thing that upset me and I just

01:48:35.900 sort of buried it and went on. And maybe I, you know, read something on social media and I didn't

01:48:40.880 even acknowledge that that was very upsetting to me. And then I find myself in this situation.

01:48:45.560 And I liken it to the Challenger blowing up. You remember when the space shuttle Challenger blew up?

01:48:50.860 This is, God, almost 40 years ago now. And I'm an engineer by training, so I really have a keen

01:48:56.080 interest in the ins and outs of that type of scenario. And what you realize is there was nothing

01:49:01.900 sudden about that horrible tragedy. Nothing about that was remotely sudden and unexpected

01:49:07.680 when you actually peel back the layers of the onion and go through the entire chain analysis

01:49:13.680 for not just the Challenger, but all the previous space shuttles. And you realize how inevitable this

01:49:21.500 was. And on that day, this was almost a foregone conclusion. Now imagine watching that as a spectator.

01:49:28.260 Oh my gosh, how could that happen? You would get an A on your DBT test because it ties into the

01:49:35.140 dialectical philosophy of everything is caused. Everything has multiple causes. And that is very

01:49:46.060 hard to accept sometimes. And it's also very hard to experience, especially in our dominant culture

01:49:55.440 that wants us to believe that there are simple answers. And there's one person to blame or one

01:50:04.560 root cause. That's what the dominant culture is trying to tell us about everything and anything, 0.52

01:50:10.560 because that's simple. And it's more complex than that, that there's always multiple determinants

01:50:17.720 of anything and that we could dissect any behavior, any problem and see the thousands or millions of

01:50:28.620 causes that led up to that behavior. I have one of the pages in front of me that I've copied from

01:50:33.520 my skills book that has so many of my notes in it. You probably remember the page. It's what makes it

01:50:38.320 hard to regulate your emotions? This is probably one of the 10, you know, this is a 350 page, 400 page

01:50:44.480 workbook. There's probably 30 or 40 pages that I have stickies in, and this would be one of the 10

01:50:49.640 most important. And it's just this great reminder just for the person listening to this. So what makes

01:50:54.140 it hard to regulate your emotions? Biology. Let's just acknowledge there are biological differences

01:50:58.660 between us. Our brains are different. I won't go into some of the details there, but anybody who has

01:51:03.980 many kids, more than one will recognize that they are simply different, even if they're raised

01:51:08.880 identically. One that we already talked about, lack of skill. Lack of skill because skills were not taught,

01:51:13.600 because good skills were pushed away, or because bad skills were reinforced. I think this comes

01:51:18.620 from it, which is reinforcement of emotional behavior. So going back to childhood. This one's

01:51:23.260 very interesting, right? Moodiness. Your mood in the moment will alter your ability to regulate emotion.

01:51:29.580 This one I can relate to a ton, which is emotional overload. So the more pressure you have on you,

01:51:35.100 whether self-imposed or otherwise, the more difficult it is. And then one that I love,

01:51:39.560 which is emotional myths, mistaken beliefs about these things. I have my own notes here. One of

01:51:44.740 them says, when I can't regulate, it is almost always the case that at least one and typically

01:51:49.980 three of these are happening. So it's very interesting. Again, three of these really

01:51:55.760 pegged to childhood, right? The biology, the reinforcement of emotional behavior, plus or minus

01:52:00.200 skill, and the emotional myths. Yes. A lot of them are longstanding patterns. And some of them

01:52:05.360 are current and also contextual. For example, there might be a person in your life, just one of many

01:52:14.160 that actually, when you display anger, gives in to everything you're asking. This could be totally

01:52:22.020 outside of your awareness, but that means that you're more likely to have that anger response with

01:52:28.780 that person in that context in the future. I had a while before my husband, ex-boyfriend at one point,

01:52:36.300 who, when we would argue, if I started to cry, he would immediately back down. And this was outside

01:52:43.720 of my awareness that this was happening, but I realized over time, I found myself crying a lot more

01:52:50.120 than I ever had before. I'm not saying crying is good or bad, but I just noticed that that was what was

01:52:56.620 happening because in that context with that person, that behavior was being reinforced. And I feel like

01:53:03.080 this could happen so subtly and it's so contextual. And why we're sometimes different with different

01:53:11.180 people is because of that. This is often, at least as it relates to BPD, is pathologized. Oh,

01:53:17.800 if you're different with different people, there's something wrong with you. You have no

01:53:21.540 core sense of identity or something, but I would say it's actually pretty normal. We're all different

01:53:27.560 with different people because the contexts often call for that. And it's adaptive to be that way.

01:53:34.320 So is it essential for everybody who's practicing DBT to also be practicing mindfulness meditation,

01:53:39.900 given the importance of that first step, which is recognizing the thought?

01:53:47.240 Well, we might have to disentangle what we mean by mindfulness meditation, because I would say

01:53:52.080 mindfulness as a skill is central to everything.

01:53:58.960 Sorry, let me rephrase the question. Given the importance of mindfulness as a central tenet to this

01:54:04.140 entire practice, is it also suggested that people use a form of meditation that practices that skill,

01:54:12.020 typically focusing on something like the breath or an object and bringing their attention back

01:54:17.220 to that every time it wanders? We have actually debated this within DBT. And I remember,

01:54:23.760 actually, there was a while that Marsha was, when I was a student of hers and therefore seeing her

01:54:29.060 every day, she was on this kick, lack of a better word, saying that we need to get all the therapists 1.00

01:54:34.820 to practice seated meditation, like you're describing, for at least 20 minutes every day. And actually,

01:54:40.840 there's a form of cognitive behavioral therapy called mindfulness-based stress reduction,

01:54:46.280 MBSR, you may have heard of it, for depression, in which they teach people who are in the treatment

01:54:53.280 to work up to that seated meditation. And they also require that therapists who do MBSR also practice it

01:55:01.860 that way. And so Marsha was thinking, do I need to require this? And I remember, even way back when,

01:55:07.340 arguing against it at the time, because I thought that's not actually practical for everybody.

01:55:14.120 Always. I think about working mom, a single mom with three kids, and to say, you need to find 20 0.99

01:55:21.980 minutes a day to do seated meditation is impractical. There have been many times in my life where that

01:55:30.040 was impractical as well. And part of this was to try to figure out, like, how do we define a DBT

01:55:35.500 therapist? How do we know when somebody is doing DBT? She never ended up requiring or saying that

01:55:42.020 therapists have to do this. But what she would say is that therapists who practice DBT have to have a

01:55:47.980 mindfulness practice. But that practice could be anything under the umbrella of mindfulness. So

01:55:55.300 you do yoga, that could be your mindfulness practice, or you do mindful walking, or you do

01:56:01.560 mindful participating in various things. That is something when it comes to clients who are

01:56:08.360 in DBT. We want them to strengthen their mindfulness muscle. Absolutely. And if I have

01:56:15.900 clients who are interested in learning to do seated meditation, that's amazing. And I would support that

01:56:23.220 entirely. I think for a lot of the clients that we work with at my clinic, that would be too big

01:56:30.420 a jump. And why Marsha doesn't say that clients need to do this. For a lot of people who are in DBT,

01:56:37.060 who might be at that more severe end of the continuum, just sitting with themselves and

01:56:43.040 their thoughts and their minds without doing anything to change it for a minute could be

01:56:48.440 excruciating. So we're trying to build that tolerance, of course, but the mindfulness skills

01:56:54.560 in DBT are much more concrete and practical and designed to be used in any moment, rather than

01:57:02.660 designed to facilitate a more formal practice. Obviously, we can't cover DBT in any comprehensive

01:57:08.900 manner. There's so much. But there are a couple of things I'd love to just highlight that I have

01:57:12.960 found very helpful. And I'd love to kind of hear you expand on them. One is opposite action. For

01:57:17.720 anybody who's done DBT, you'll grin or grimace, depending on because how hard it can be sometimes.

01:57:23.500 Do you want to explain to people what opposite action is? And when we use it? What's the use case for

01:57:27.560 this? Yeah, I did my dissertation on opposite action. I did. So opposite action is a skill that

01:57:35.300 falls into the emotion regulation module. And it's a skill for changing an emotion that you don't want

01:57:41.660 to have. And it's simple in concept and hard to execute because simply put, it's engaging in the

01:57:52.040 opposite of what your urges are telling you to do. And that's why it's called opposite action.

01:57:56.920 So we know that from emotion science, from our own experiences, that our experience of emotions are

01:58:03.180 associated with an urge to act in particular ways. So when we feel sad, we have an urge to retreat

01:58:11.940 or withdraw. When we experience anger, we have an urge to lash out. When we experience shame,

01:58:19.660 it's to hide. Fear, it's to fight or flight. And so what opposite action says is that when

01:58:26.900 your emotion does not fit the facts of the situation or is too intense for the situation

01:58:33.280 and you want to change it, a way to change it is to act opposite to your urges. So when I'm sad,

01:58:39.500 instead of withdrawing, I activate. When I'm fearful, instead of running away, I approach kind of like

01:58:46.040 the exposure we were talking about earlier. When I'm experiencing shame rather than hide,

01:58:51.220 I actually confront or disclose and so on. So it is really hard to do, but you get better at it

01:59:00.300 over time. I will say that if you practice, I don't know if that's been your experience.

01:59:05.060 It has been, but what I want to tell you, and I guess you'll appreciate this given your background,

01:59:08.640 especially as I mentioned earlier, anger being a profound emotion that I'm very familiar with.

01:59:13.160 The other one is, I don't know what the underlying emotion is. I haven't really figured it out yet.

01:59:17.600 I don't think it's sadness, but it produces a phenotype of needing to isolate,

01:59:22.180 just a desire to completely isolate. So these are two areas where opposite action becomes very

01:59:27.420 helpful. One of the really interesting things that if you told me this five years ago, I would

01:59:31.660 have never believed it, but it's remarkable is the use of cold water to calm the nervous system

01:59:38.060 in moments of high fight or flight mode. So that's part of the opposite action effect there. I feel

01:59:43.720 angry. I'm going to go and do something that's really calming, which is take an ice shower or

01:59:48.900 jump in the cold pool. This is nice in the winter here in Austin, because we still have pools open

01:59:53.360 and they're really cold in the winter, but that's harder. Those are harder to do. As you probably can

01:59:58.340 imagine, when you're at nine out of 10 activation and your desire is to scream or break something,

02:00:05.980 to then walk yourself back from that is harder.

02:00:09.160 where I have found opposite action to be remarkably helpful and helpful to the point where it's now

02:00:15.420 the norm. This might be my biggest win so far is when all I want to do is isolate, forcing myself to

02:00:22.880 go and play with my kids. And I remember the very first time this happened is about a year and a half

02:00:27.900 ago. And for reasons I didn't understand, it was a Sunday morning. You know, I wanted to sit in the

02:00:33.780 office and do work and exercise and just do my own thing and be my own thing. And my wife said,

02:00:39.880 Hey, we're going to go to Barton Creek and play on the rocks and throw rocks in the water and stuff.

02:00:45.060 And that's the sort of thing I would have said, absolutely not. I'm too busy. I'm overwhelmed.

02:00:49.740 I need to just do this thing. And she would have accepted it. She would have been upset and she

02:00:53.800 would have accepted it and she would have left. And I was like, okay, let's go. Now I didn't want to go

02:00:58.320 at all, Shereen. I mean, the thought of not getting my work done and missing a workout potentially,

02:01:03.980 and then going to some place where it's totally unstructured and there's going to be other kids

02:01:09.460 potentially, and it's going to be loud. Like everything about that was unappealing. And we

02:01:14.900 had this amazing time doing nothing, literally playing games, like who could get across the creek

02:01:20.500 without getting the most water in their shoes. Exactly what you'd expect. And then on the way home,

02:01:25.060 we stopped and got a burger and fries, like the last thing I'd want to do, right? Like we did

02:01:29.060 everything I would never want to do. And I got home and I felt great. And I didn't get as much

02:01:34.780 work done. You do that enough times that you realize this really works. This is the key. For me,

02:01:40.820 this is important. When I don't want to engage with anybody, go and engage with my family because

02:01:46.940 that's the drug to get out of this. Yeah, I think opposite action is really a remarkable tool.

02:01:53.060 Think of a simpler one, smiling when you're furious.

02:01:56.740 And meaning it. What Marsha talks about is this opposite action all the way, because we all know

02:02:03.100 what a fake smile is. And a fake smile, while you're also in your mind thinking, oh, what an

02:02:08.720 asshole, I hate this person. That's not opposite action, because that's what we might say half-assed 1.00

02:02:14.580 opposite action. And it's not going to work because your mind is still going to be angry. But what's going

02:02:20.440 to happen? Really what we're talking about with opposite action is if we act opposite to our

02:02:25.200 urges, we're sending the feedback back to our brain to feel a different way. I think a lot of people

02:02:31.260 relate to the idea of doing opposite action, like what you said, but also with when you're feeling

02:02:36.620 socially anxious. Like you want to avoid going to the party or speaking up in class or at work

02:02:43.700 because you're anxious. And maybe you have a long history of avoiding saying anything or doing

02:02:48.840 anything because you're anxious. So opposite action would be to say, throw yourself into that,

02:02:54.420 go to that party, even though you don't want to, and then throw yourself into the party, which is what

02:02:59.740 you described with your family. Like you could have gone along physically, but all the while been

02:03:05.340 thinking, oh, I need to be back home. Yeah. I could have been sitting there on my phone or goofing up.

02:03:10.100 Yeah. Or thinking this is stupid or whatever, but you threw yourself into it when you were there. 1.00

02:03:14.960 And I think that that's the critical piece. It's not just the moving your body there. It's throwing 0.98

02:03:19.540 your mind into it as well. What else do you think it'd be really interesting for a person who's never

02:03:25.140 heard of DBT to understand as they themselves contemplate, hey, is this something, is this a new

02:03:31.400 skill I should learn? It's no different than saying, I'd like to learn tennis because I know that as I age,

02:03:40.100 full court basketball might be hard for me, but tennis is something that I'll be able to play

02:03:45.680 for longer. Therefore, I want to go and learn this skill. I'm going to need to coach. I'm going to need

02:03:51.020 to practice. And a year from now, I'll be better than I am today. Do you think that's a good way to

02:03:56.340 think about DBT? Well, I do with some caveats. Anybody who reads any news or is living their lives

02:04:05.260 right now knows that what we're hearing about is the idea that we're in a mental health crisis or

02:04:10.600 that there's endless mental health crises right now. And what we know is that there are just simply

02:04:15.560 not enough mental health providers to treat all the need that's out there. And what that has meant

02:04:22.860 on a practical level is that there are huge, long waiting lists for treatment everywhere for most

02:04:29.260 people. We don't want that to deter people from seeking out help when they need it. But the point I

02:04:35.680 want to make as it relates to that is that I don't think everybody needs full-on DBT. And we don't yet

02:04:41.840 have the science, really. This is actually an area of research that I'm interested in, is trying to

02:04:47.440 figure out who does need the full package of DBT versus who can benefit from a lighter touch, a lower

02:04:55.420 dose, whatever word you want to use there. Because we want to be efficient in our mental health

02:05:02.540 delivery. And we also want people to learn to reduce suffering of people on a mass level.

02:05:09.280 Is DBT something, sorry to interrupt, but this will fit into what you're saying. Is DBT something that

02:05:14.240 can be done somewhat effectively on your own? Meaning with manuals, with books, with videos online,

02:05:22.180 versus the way you would work with people who are much sicker, where you have to be working with

02:05:27.680 them directly in person. So this is what we don't know yet. I think we have some assumptions about

02:05:33.060 this. But I don't even know if our assumptions are that valid. But I think, you know, the assumption

02:05:39.920 was always, for example, that if somebody is experiencing suicidal thoughts, they absolutely need some form

02:05:49.160 of treatment, and it needs to be in person, and it needs to be X, Y, and Z. And I think COVID actually

02:05:55.760 threw us into this new world that we weren't expecting, because we had to start treating people

02:06:01.580 who were suicidal, virtually, for example. And we were able to realize that this idea that we had to

02:06:07.620 see people in person was a myth that we believe. And there were reasons why we believed it. But there

02:06:14.880 doesn't seem to be any, as far as we know so far, any added risk of seeing somebody through telehealth

02:06:22.480 when they're suicidal. So I think a lot of our assumptions about what people need are assumptions

02:06:29.800 that we don't actually know a lot about. An area of research that I'm interested in, and that I

02:06:35.820 actually applied for some funding to do, is to do kind of a stepped care model of DBT, to start

02:06:43.500 everybody with what we might call a low dose intervention, like videos of skills, and see

02:06:50.380 what percentage of people benefit from that, and from that alone, versus what percentage of people

02:06:58.720 don't benefit enough, need something else. And then what can we add to that, that would be a slightly

02:07:05.340 step up, like maybe some phone coaching, you get a call with somebody once a week about how to apply

02:07:10.500 the skills in your daily life, then test it again, right? And then if you're not responding

02:07:15.700 to that, maybe then you get offered the full package of DBT, or something else. And we basically

02:07:22.200 can identify through that kind of study, what are the sequences of care that are going to be most

02:07:28.960 effective, that will help the most people, and can be disseminable. So that's an area of research

02:07:35.680 that I would love to do. We don't have a lot of knowledge about that. But I'll say, and I think

02:07:41.240 we spoke about this very early on, is that I honestly believe that anybody could benefit from

02:07:46.940 learning DBT skills. And so to that end, I would say yes, I think there is a value to your listeners

02:07:54.400 to say, expose yourself to some of these skills, see if, and there are videos, there are books,

02:08:00.440 there are things that you could do to learn more about them, see if you resonate with them,

02:08:05.940 see if you can apply them on your own. And if you want to know more, or you're struggling to apply it

02:08:11.480 in your life, then that might be where you could reach out for help and find a DBT therapist.

02:08:18.180 Now, speaking of that step, Shireen, how does a person know when they find the DBT therapist? How can

02:08:24.120 they verify that they're well trained? You're probably an exception in that you trained

02:08:30.040 directly with Marsha. There are obviously a number of people who train directly with her, but that's

02:08:35.460 not scalable. So at some point, you're going to meet a potentially wonderful therapist who doesn't

02:08:39.780 have that lineage. So how is the field of DBT self-regulated or self-policed?

02:08:44.680 So it's been a longstanding process to try to figure this out. Mental health is really screwing

02:08:54.620 in this way, because there are so many ways in which a person can become a therapist,

02:09:00.820 hang a shingle outside their window and practice therapy. And that person can call themselves a DBT 0.77

02:09:06.760 therapist, or a CBT therapist, or any kind of therapist, and may not have the credentials or

02:09:13.160 training to back that up. I always tell people to proceed with caution and to do your research when

02:09:19.560 you're looking into finding a mental health provider. Marsha was against this for a long

02:09:25.320 time. She was against this idea of certifying DBT therapists. She didn't want to have regulatory

02:09:33.700 role. She wanted people to learn DBT and to just sort of get DBT out there. But then she was hearing

02:09:41.640 more and more stories, as we all have now, of people saying that they received DBT and it didn't work.

02:09:48.320 And then you ask them what happened in their treatment, and you hear details about their

02:09:53.680 treatment that were clearly not DBT. And the worst case scenario is somebody dies by suicide or has a

02:10:01.260 terrible outcome, thinking that they're getting DBT when they're not. So a few years ago, she started

02:10:08.400 the Linehan Board of Certification, LBC, which has started a certification process for DBT therapists.

02:10:16.240 So what I will say, all people that are certified by LBC to be DBT clinicians are likely good

02:10:23.700 clinicians, good DBT clinicians, because they've met all of these standards. But not all people who are

02:10:30.020 not certified are bad DBT therapists, right? Because there's a number of DBT therapists who have just

02:10:35.060 elected not to go through the process of certification. If you're first starting to think seriously about

02:10:41.800 DBT, you might start by looking up certified DBT therapists, but recognizing that that's not the

02:10:47.780 only criteria to use.

02:10:49.520 Are there any other questions that a person can ask to determine if the pedigree of the person who's

02:10:57.400 going to be conducting their therapy is truly in line with the principles of DBT as opposed to

02:11:02.360 something that's been bastardized and sort of misused?

02:11:06.220 So I'll share another Marcia anecdote in response to that question, because relatively early on,

02:11:13.780 sort of after the initial trials of DBT were put out, showing that DBT was effective,

02:11:20.780 insurance companies started getting interested and wanted to pay for DBT, but didn't want to pay for

02:11:27.620 non-DBT. And so they would call Marcia up and they would say, this person says they're doing DBT,

02:11:34.300 how do we know if they're really doing DBT so that we can reimburse for the service?

02:11:39.420 And she thought about it and ultimately said, ask the DBT provider if they're on a consultation team.

02:11:46.480 Now, I think that this is oversimplified by far, but I'll explain that one of the aspects of DBT

02:11:53.540 or one of the components of the full package of DBT, in addition to individual therapy and skills training,

02:11:59.940 is that the DBT therapist, him or herself, attends a weekly consultation team meeting with other DBT

02:12:08.240 therapists. And the consultation team meeting is a place where DBT therapists talk about their

02:12:16.220 experiences delivering DBT with an aim towards improving their own adherence to the model and

02:12:23.040 their motivation. It's often called therapy for the therapist. And I think Marcia's response to that

02:12:29.260 question was important because in many places, somebody might say, I want to learn DBT and I

02:12:36.440 can, a provider might say, oh, I've learned the DBT skills and I can teach my clients DBT skills

02:12:41.900 and I'll just pick and choose what I want to do out of DBT. And the first thing they elect to drop

02:12:48.420 is the consultation team meeting because it's time, right? It's time and effort and it's centered on

02:12:54.440 you improving yourself as a therapist. I think it holds up though, as a reasonable question to know

02:13:00.660 to what extent is the person that you're looking into adhering to DBT principles is to ask whether

02:13:07.940 they're part of a DBT consultation team. That's a great litmus test, actually. I really like that.

02:13:13.420 I don't know how many people, it'd be interesting to know.

02:13:16.700 Shereen, this was fantastic. I know we're going to get to meet in person in about six weeks. So I'm

02:13:20.340 really looking forward to that. Thank you so much for your time. This is a hard topic. It's so big

02:13:25.460 and it's so big to get your arms around it all. And I want people to come away from this, not at

02:13:29.360 all thinking that they know what DBT is necessarily from this, but I hope we've piqued someone's

02:13:33.840 curiosity such that they go out, they watch some videos, they maybe pick up a book or a skills book

02:13:38.860 and decide, hey, is there something in here for me? And maybe for some, it means going as far as

02:13:44.160 someone like me has gone and saying, I'm going to make this a regular part of my training.

02:13:47.620 It was really fun talking to you. So thank you.

02:13:49.860 Thanks, Shereen. Thank you for listening to this week's episode of The Drive. If you're

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The Peter Attia Drive - August 22, 2022

#219 ‒ Dialectical behavior therapy (DBT)： skills for overcoming depression , emotional dysregulation, and more ｜ Shireen Rizvi, Ph.D., ABPP

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