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

Episode Date: August 22, 2022

View the Show Notes Page for This Episode Become a Member to Receive Exclusive Content Sign Up to Receive Peter’s Weekly Newsletter Shireen Rizvi is a Professor of Clinical Psychology and Psychiatry at Rutgers University, where she is also the Director of the Dialectical Behavior Therapy Clinic. This episode focuses specifically on dialectical behavior therapy (DBT), a skills-based technique which was originally developed to treat borderline personality disorder (BPD) and has since been adapted to treat depression and other mental health conditions, as well as to help people who have difficulty with emotional regulation and self-destructive behaviors. Shireen explains the origins of DBT and how its creator, Dr. Marsha Linehan, came to find a need for something beyond cognitive behavioral therapy (CBT) when attempting to treat patients with suicidal behavior. From there, Shireen dives into how DBT works to resolve the apparent contradiction between self-acceptance and change to bring about positive changes in emotional regulation, interpersonal effectiveness, mindfulness, distress tolerance, and more. She also provides examples for how one can apply specific skills taught with DBT such as accessing the “wise mind,” applying radical acceptance, using the “DEAR MAN” technique, and utilizing an emotion regulation skill called “opposite action.” Finally, she explains how the tenets of DBT offer benefits to anyone, and she provides insights and resources for people wanting to further explore DBT. We discuss: The basics of dialectical behavior therapy (DBT) and how it differs from cognitive behavioral therapy (CBT) [3:00]; Treating depression with CBT: history, effectiveness, and how it laid the groundwork for DBT [8:15]; Marsha Linehan’s inspiration for developing DBT [16:00]; Explaining borderline personality disorder (and associated conditions) through the lens of DBT [20:00]; How work with suicidal patients led to the development of DBT—a dialectic between change and acceptance [35:30]; Details of DBT: defining the term “dialectical” and how to access the “wise mind” [44:30]; Practicing mindfulness and radical acceptance in the context of DBT [51:00]; Applying “radical acceptance” to tragic scenarios [1:02:00]; The five domains of skills taught in DBT [1:07:15]; Why Marsha chose borderline personality disorder as her focus when developing DBT [1:13:30]; Is there any benefit in doing DBT for someone without a pathological condition? [1:15:45]; The DEAR MAN skill of DBT [1:20:00]; Adapting DBT skills for adolescents and families [1:31:00]; Identifying vulnerability factors, increasing distress tolerance, and the impact of physical pain [1:33:45]; The DBT chain analysis: assessing problem behaviors and identifying vulnerability factors [1:44:30]; Why the regulation of emotions can be so challenging [1:50:30]; The importance of mindfulness skills in DBT [1:53:30]; Opposite action: an emotion regulation skill [1:57:00]; Advice for those wanting to explore DBT [2:03:15]; Finding a well-trained DBT therapist [2:08:15]; More. Connect With Peter on Twitter, Instagram, Facebook and YouTube

Hey everyone, welcome to the Drive Podcast. I'm your host, Peter Atia. This podcast, my website, and my weekly newsletter, I'll focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content and health and wellness. Full stop, and we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in-depth content if you want to take your knowledge of this space to the next level. At the end of this episode, I'll explain what those benefits are, or if you want to learn more now, head over to peteratia MD dot com forward slash subscribe.

Now, without further delay, here's today's episode. My guess this week is Cherine Rizvi. Cherine is a professor of clinical psychology and psychiatry at Rutgers University, where she also serves as the director of the dialectical behavioral therapy clinic. She earned her doctorate in clinical psychology from the University of Washington, where she studied under Dr. Marshall Linahan, the creator of dialectical behavioral therapy clinic. She earned her doctorate in clinical psychology from the University of Washington where she studied under Dr. Marshall Linahan, the creator of dialectical behavioral therapy, abbreviated DBT. Since joining the faculty at Rutgers in 2009, Sherin has taught courses and conducted research on topics including DBT, cognitive behavioral therapy or CBT, personality disorders, and trauma. In this episode, we focus specifically on DBT.

We cover the origins of DBT and how dialectical behavioral therapy differs from its cousin, cognitive behavioral therapy. We talk about how its creator, Martialinahen, came to find a need for something beyond cognitive behavioral therapy, both to help her and to help her patients. Talk about the structure of DBT

and how it is oriented as a skills-based technique. We talk about something called wise mind, emotional mind and reasonable mind and how these things are connected. We talk about radical acceptance. We talk about different frameworks, for example, something like Dear Man, which anyone who's done DBT will be familiar with as a framework for interpersonal interactions.

We talk about one of my favorite ideas called opposite action. We also discuss who can benefit from DBT, how it can help children, how mindfulness plays a part of DBT, and how someone can find a well-trained DBT therapist. Lastly, I have a huge personal interest in this because I've been practicing DBT for two years, and I think it's safe to say, I feel like I'm barely scratching the surface of what this is about. So I have no delusion that listening to this podcast is going to offer you everything you need to know about DBT. But my hope is that for those of you who listen to this, who see that there might be some

benefit in this technique, your curiosity might be peaked enough that you go out, watch the educational videos that exist on this, pick up a workbook, work your way through it, and potentially find a therapist if you think this is something could be helpful. So without further delay, please enjoy my conversation with Charene Rizvi. Hey, Charene, it's great to finally meet you, not in person, but better than being on the phone, I guess. Yes, same here. You know, people on this podcast have probably heard me in a couple of episodes,

reference this thing called DBT. I've never really gone into much detail about it, but it's something I've wanted to, obviously, have a dedicated podcast around, and now we're finally going to get to do that. So maybe we can just start by defining what it is a little bit before we get into its history, its founder, your involvement, and things like that. If you're at a party and somebody said, Sherina, I heard that you're a DBT therapist practitioner. Can you tell me what that is? What would you say? DBT stands for dialectical behavior therapy, abbreviated DBT, and it's a form of therapy or a form of talk therapy that is largely inspired by cognitive behavioral therapy, also abbreviated as CBT. So

we often say that DBT is a form of cognitive behavioral therapy that was designed for individuals that have complex mental health problems and originally designed for individuals that are suicidal or self-harming and who may meet criteria for a disorder called borderline personality disorder. At its simplest, I would say it's a form of cognitive behavioral therapy that was designed for more complex people or presentations. But then, of course, there's a lot more nuance

beyond that. Maybe give people a bit of background on what cognitive behavioral therapy is. I mean, that term, I've heard a lot, but truthfully, I don't know much about CBT outside of CBT-I, which is cognitive behavioral therapy for insomnia, which we have referred, I would say over the past five or six years, probably a dozen of our patients to CBT-I practitioners. I think I can say without exception, it has always proved to be incredibly valuable, not just incrementally valuable, but incredibly valuable. That's the very limited experience that I have with CBT is through that one narrow lens. Is there something more broadly we can say about CBT that then allows us to contrast it with DBT?

CBT refers to maybe a class of talk therapy and could often be used to contrast it with other kinds of talk therapy, but some of the distinguishing features of cognitive behavioral therapy is that it's present focused. So focused on what's happening for people right now in terms of the problems they're experiencing and less focused on one's history, one's childhood, less focused on the sorts of things that have led to the person experiencing the problems that they're experiencing.

So it's present focused, and as the name implied, it's focused on working with thoughts and behaviors that go along with the problems that people experience. So in CBTI, for example, it would be, what are the thoughts that are contributing to your insomnia and how do we work on modifying or changing those thoughts that you're having in order to increase the likelihood that you fall asleep or stay asleep?

What are the behaviors that you do that promote sleep? What are the behaviors that you do that get in the way of sleep and how do we modify that? So at its most concrete level, it really is working with thoughts and behaviors that in the present that are contributing to your problems right now. So it's very much an active problem solving approach with people who don't have a lot of experience with therapy or receiving mental health treatment, they might have an idea based on the media or TV or movies that the best therapy is one where you just go in and talk about whatever's on your mind. And CBT and similarly DBT is much more structured and guided than that.

And the other distinguishing feature I will say about CBT and DBT is that it's evidence-based, meaning that we construct treatments in a way that we could measure its effectiveness. And if we find that something is not effective for people, then it's not likely to stay in the therapy. That's our goal, anyways, to be as empirical and scientific in our approach as possible. So, how long has CBT been around as a discipline? Probably the figure that is associated with the beginning of CBT is a man named Aaron Beck, who died last year, I believe, at the age of 100 or something like that number. I would say it was probably the 60s

in which he first started developing his form of cognitive therapy. He was trained as a psychoanalyst and was seeing that it wasn't all that useful for a lot of the patients that he was treating in psychiatry. And so he started developing an approach that was much more about changing the way people thought about themselves and others. Let's talk about Marsha, Marsha Linhen, who's I think it's safe to say really the creator and founder of DBT, is that a fair statement? Yes, for sure. So, tell me about her journey. Presumably, she had tried CBT both as a patient and maybe even as a therapist before realizing that there was a way that it could be improved upon for at least a subset of patients and

or a subset of problems. Would that be kind of a fair statement? Yeah, so the origin story of DBT was that originally, Marsha set out to apply what might be considered standard CBT to folks who were chronically suicidal. Perhaps beginning in the 70s, she was receiving advanced training at Stony Brook in New York. At that time, Stony Brook was considered one of the premier places to learn and apply behavior therapy.

And back in the days of the 70s, 80s, it was really the heyday of behaviorism. And the idea was, in many ways oversimplified, but the idea was that we could treat any mental health problem with behavior therapy in very few sessions just by applying these standard principles of what we know about behavior change. Can you give me an example of what that would be? Does that mean that if a person was clinically depressed and came in, and they were suicidal, what would the CBT approach have been in the 70s or 80s to address that concern?

I can come back to depression in suicide in a minute, but I might start with anxiety disorders, because this is actually what behavior therapy in CBT was probably most prolific about in those days. And the idea was that you could have somebody who came into treatment with a fear of something, a phobia. It could be something like a fear of heights or a fear of spiders or it could be a fear of social situations, social anxiety. And the behavior therapy approach to this or the cognitive behavioral therapy approach to this would be to teach people competing thoughts. So rather than thinking this thing will kill me, I can learn to have thoughts like I can tolerate this. This might be difficult, but I can handle it or even have thoughts like this is not going to kill me. But those thoughts were only one part of it. The other piece of it was the more behavioral piece, which is

exposure, basically saying that how you're going to get over your fear of spiders is not to talk about it every week for an hour with somebody, but is actually going to be coming into contact with spiders repeatedly over and over again so that you learn that you can handle it, but you also learn that the feared outcome is not going to occur. Change your thoughts and get exposure. Change your thoughts, get exposure. Exactly. And the getting exposure is changing your behavior because you want to run away or avoid. And instead, it's saying come into contact with approach, something that you want to avoid. And so what they were finding in these early days of applying CBT is saying people may have gone to psychoanalysis, which was the dominant paradigm of therapy in those days.

And by the way, this is almost exclusively a rich white person issue when I'm talking about who was receiving treatment for mental health problems. That's what I'm talking about back in those days. days, largely. People could go to a psychoanalyst and talk about their fears for months and years, and not necessarily do better with them. And so CBT comes along and says, actually, we could do this sometimes, depending on what the fear is in one session. There were people who would do like a three hour session to quote unquote, cure somebody of euphobia in finding that it worked. And so then you say, okay, how do we take those principles to something like depression?

And this is what Aaron Beck started to do with cognitive therapy more was noticing that people who have depression tend to think in very particular ways. They have negative interpretations of almost everything and also about themselves, about their future, about others. And so a cognitive behavioral approach to depression would be about working on changing those thoughts to be more balanced and evidence-based.

And then also the behavior change that goes along with depression is usually about getting active. So when somebody is depressed, the tendency is to retreat, shut down, avoid, and the behavioral treatments for depression would be to get people activated and to solve the problems that are causing the depression, whether it's unhappiness with the job, unhappiness with the relationship, and work on targeting the problems that are causing depression in a systematic way. How successful was it? You mentioned earlier that evidence is a very important part of this. How were they able to tally the results and determine if their intervention was in fact better

than the standard of care at the time? The history of psychotherapy trials is largely based on a paradigm known as randomized clinical trials, where you would recruit individuals who meet certain inclusion criteria, say, somebody meets the diagnosis for depression, and then you would randomize them to either, say, receive 12 weeks of cognitive behavioral therapy or receive nothing or receive treatment as usual or standard of care, and then evaluate outcomes over time. And with things like depression and anxiety disorders, there are these standard measures that are popular within our field where we have developed benchmarks for what we're trying

to get to, you know, what might be considered a success. And I would say that in general, the trials for CBT for things like depression and anxiety are overwhelmingly positive, meaning that most of the trials, especially in the early days when you were comparing CBT to nothing or treatment as usual, found very large effects for CBT in those settings. Now, I think where we see or where we'll come back to Marsha emerging is recognizing that, of course, none of these treatments were 100% successful for everybody. And more than that is that when you look at these studies

and you see who were these studies done with, the inclusion criteria, meaning what allowed somebody to be in the study, were often quite narrow. For example, with a depression study, the person might have to meet the criteria for a diagnosis of depression, but not have suicidal behavior. So people with suicidal behavior may be excluded from a lot of those studies, which makes sense from a research point of view in some contexts, but in other contexts, doesn't make sense because of course we know that a lot of people

who experience depression are also suicidal. So if you're removing suicidal people or not allowing suicidal people to be part of this research, then we don't know ultimately if the treatments work for those populations. Marsha as a young girl, I think, was diagnosed with schizophrenia, is that correct? And was treated with electro-convulsive therapy and all sorts of things that are still used today, but probably not as frequently and probably with a bit more particular attention to the use case. Probably used more liberally than I'm guessing.

So, Marcia was a teenager, I believe, at the time that she was receiving a lot of treatment. And this was in the late 60s, if I'm remembering correctly, when she was born, now that I'm thinking about it, but it was before CBT was really in the picture. And she was hospitalized for being suicidal and chronically self-injuring, doing a number of things to cause physical harm to herself as a way of to herself as a way of relieving emotional intensity and overwhelming emotions. So at the time, there was not a lot of treatment options that were available. And the medical model was to treat with really strong meds, antipsychotic meds at the time, or to use something like electro-comulsive therapy. And so those were the treatments that she was exposed to from a very young age, in addition to therapy, but the types of therapy that she was receiving at that time

were unlikely to be anything like the cognitive behavioral treatment we know today. So how did she find her way from being almost institutionalized to eventually getting an education and herself becoming a therapist? What was that journey that went from that teenage girl to the person who created DBT? She has written about this in a memoir as well as described it in a piece in which she in the New York Times, which was a piece where she kind of came out to the world as having been someone who experienced her own significant struggles with mental health.

And I say that as a preface because for that article in the New York Times came out, I believe in 2010, 2011. So for most of her career, she was not forthcoming about this, her own personal struggles. She would tell people that were close to her new, her students. I was one of them knew about this experience, but she wasn't public about it. And she would long say that the reason for that is because she wanted DBT to be judged on its

merit empirically. She did not want DBT to be judged on her personal story alone. She wanted this to be a scientific treatment that lives and dies by its outcome, she would say. So when she would talk about how DBT developed to the public is she would talk about it leaving out this earlier part of her own history. So the earlier part of her own history that she describes is that she had a spiritual moment when she was in one of these institutions. And the spiritual moment was that she describes experiencing God in a very dark moment of her own life. And in that moment, she realized that she felt the love

of God and felt that she could serve this purpose in life which is to get out of hell her own experience and then to work her entire life to get other people out of hell. And that was how she took this spiritual experience and developed her life's work based on that. How old was she Shireen at that time? I would say as best I remember in her late teens or early 20s. Kind of profound to follow through on something that you could argue, well, God, you're still so young when that was happening. And was she at some point here diagnosed as having a borderline personality disorder as well? Or is that something that is more retrospective where it's sort of

like looking back, she was probably misdiagnosed as having schizophrenia. I mean, what was the state of understanding of her actual condition? I believe that she was probably, you still see this today, but when people are unclear about how to explain someone's problems, they get given almost every diagnosis in the book. And now this would have been before the criteria that we now know as borderline personality disorder being defined in the way it is most well known would have started in the third edition of the DSM

which came out in about 1980. So the criteria that we have now to define borderline personality disorder was not the same as when she was receiving treatment. So I believe that she had a number of diagnoses attributed to her. I can't remember. It's quite possible that borderline personality disorder

was one of them because of course, that's also the diagnosis that they give people when they don't know how to treat them. What are the criteria? Tell folks what borderline personality disorder is today. So borderline personality disorder is considered a complex mental health disorder. There are nine criteria of borderline personality disorder as defined by the DSM. And in order to meet criteria or to have the condition, you have to endorse five of the nine, which actually means

that ultimately it's a really heterogeneous disorder because there's all these different combinations and different ways in which one can meet criteria. One of the things that Marsha did was to restructure the different criteria borderline personality disorder in a way that perhaps is more understandable and also makes more cohesive sense. And to say that it's a disorder of dysregulation across a number of different domains. So the core domain of dysregulation that we see in borderline personality disorder is what we refer to as emotion dysregulation. And this is largely defined by people's experience of emotions as feeling like they have very intense emotions. They don't feel like they can control their emotions very well.

Their emotions change very rapidly. So that's referred to as affective ability that the emotions will go from intense sadness to intense shame, to fear, to joy, very quickly, and seemingly without a lot of reason. So emotion dysregulation is part and considered core to the disorder of borderline personality disorder. And then these other domains of dysregulation

stem from emotion dysregulation stem from emotion dysregulation and include behavior dysregulation. So not having control over or feeling like you don't have control over your behaviors. This is associated with a lot of impulsivity and behaviors that go along with impulsivity. So substance use, reckless spending, impulsive sexual behavior, impulsive driving,

behaviors that are experienced as impulsive and potentially could cause problems for the person. Impulsive eating is another. I mean, it sounds like there's quite an overlap, at least in some of those with bipolar disorder, bipolar one. I don't know about the effective ability, but certainly the main side of it sounds like it might be consistent with some of that dysregulation.

I'm guessing that's what makes psychiatry so difficult is you don't have biomarkers, you don't have imaging scans that give you diagnoses, right? We don't. And so there is. You write a lot of overlap. And probably the ones that overlap that is more consistent or difficult to discriminate is bipolar 2.

Because bipolar 1 is associated with longer lengths of either a pure manic state or a pure depressed state. Bipolar 2 might have manic states, but it is shorter in duration or might not be super manic, right, as high. And so that's often really hard to discriminate from somebody who has borderline personality disorder. And generally, what we're talking about with BPD,

as opposed to bipolar, is that we actually see the mood changes happening more frequently within BPD than with bipolar 2. But I probably oversimplifying, but that's what I would be looking for if I was trying to assess the difference. A person with BPD, what are the challenges that they face in the world? Let's just assume this is a person of totally normal intelligence and all physical capabilities are fine. And this is sort of the one issue, this one psychological issue. How does it manifest itself for that person when they're in school, when they're in college, if they get married, if they have kids like help us understand how this condition makes life more difficult for the individual and those around them. One thing I'll say is that you rarely will see this condition in isolation of anything else.

And again, this speaks to one of the complexities of trying to study a psychiatry that I think on average, people whom e-crataria for BPD have three to four other mental health problems at the same time. So they'll also me criteria for depression or an anxiety disorder or a substance use disorder or... And those things aren't stemming from the BPD. These things are, we believe, independently there as well. I think it depends on who you ask, because I would say as somebody who is trained mostly

behaviorally, I would say the diagnosis matters less than how we conceptualize these problems. And to that point, I would agree with you we could say emotion dysregulation is central to all of those things, but the diagnostic system as we currently have it does not allow for that. So they would say, if somebody meets criteria for these other disorders, they also have these other disorders. So how somebody with borderline personality disorder lives their lives, I would say, it's complicated,

and it ranges. On one end of the continuum, we see people who have severe problems associated with BPD such that they struggle to hold onto a job so they don't work and they're on disability or receiving Social Security. They can't maintain relationships. And why is that? Why are relationships blowing up and why are they not able to hold down a job?

What's the fundamental issue? We're fundamental issues that are impairing them. From a DBT perspective, we would say that it all comes back to difficulty regulating emotions. So that if I experience intense emotions that I feel like I can't control, When I get angry, I lash out. When I get scared, I run away or avoid. One of the criteria that goes along with BPD that you could see as tied with emotion dysregulation problems is what's referred to as fears of abandonment. So a person with BPD often will have a lot of fear that a person that they love or are close to will leave them.

And if I am in a relationship where I am afraid that the other person is going to leave me all the time, that may cause me to behave in ways that are frantic, chaotic, and actually paradoxically have the effect of causing the other person to be more likely to leave, texting the person calling the person relentlessly. If a person doesn't come home or call at the time that they say they will, you know, having the experience of feeling like I'm losing it because I don't know where that person is or perhaps they've left me. As a result, if I have BPD, I experience intense fear, intense shame, intense sadness, and now I don't know what to do with this intense behavior, and I may self-injure as a way of leaving

that emotional intensity, or I may threaten suicide as a way of getting the person to come back to me. And maybe I'm doing this without even having awareness that that's the effect of my behavior. I just know that in this moment, I don't know what to do. I feel entirely out of control and I need to do something to fix it in this moment.

What is the mortality of BPD? I was very surprised to learn recently that anorexia nervosa has probably the highest mortality of any psychiatric condition, I would have guessed depression presumably. Where does BPD stand in terms of mortality, either through self-harm and neglect, potentially, or are obviously suicide? I sometimes get into the weeds a little bit about this, and when as an academic and psychologist, and someone who studies suicide, I review a lot of manuscripts and grant proposals and I am always saddened and amused when I see people write about a disorder and say, this disorder has one of the highest rates of suicide.

Because if you look at it, it seems like every disorder has one of the highest rates of suicide. And I think it's because we don't know how to study this very well, honestly. We don't know how to study this very well. Honestly, we don't know how to determine of the people who die by suicide. What are the mental health conditions that they had? And what is the relative risk, according to these different disorders? Well, especially when you overlap, because as you said earlier,

if a person with BPD also suffers significant depression, if they commit suicide, are we attributing that to depression? I think my question more broadly is knowing that one could never tease that out. How risky is it for an individual? Understanding all of the comorbidities that tend to cluster with it. I will say it's very high. And one way in which I can answer this is another criteria for BPD is repeated or chronic self injury or suicide attempts.

More than 75% of people, and in some studies, 90 to 95% of people who meet criteria for borderline personality disorder engage in self injury or have made more than one suicide attempt in their lives. This tells us a couple of things. One is that on its own is considered a very high-risk behavior because people who engage in self-injury,

even if they don't intend to die, there could be accidental depth as a result of self-injury. What are some examples? I mean, people probably think of the most common examples of people cutting themselves or burning themselves. What are some other examples of self-injurious behavior that people engage in? Head banging or punching or hitting oneself. There are multiple forms of cutting that include different objects to cut, but could also be people really intensely scratching themselves to the point where they draw blood. There's overdosing is considered a form of self injury. You know, you have to determine,

is this with intent to die or not? but there are people who overdose without intent to die as a way of hurting themselves. More rare, but other forms of self-injury may involve ingesting, toxic substances, etc. So this is also, I think, evolved over time, or we didn't know how to study it very well over the years, because even in my career, I feel like 20 years ago when we were talking about self-injury, we were talking much more about things like cutting or burning. And I feel like as there have been more people interested in studying self-injury,

we're also finding out about other ways in which people cause harm to themselves. And then there's all sorts of debates about whether this is considered self-injury or not because some people might say, I have binge eating or I overeat and I do that intentionally, even though I know it's causing harm to myself,

whether we classify that diagnostically as self-harm or not is one question, but whether a person considers themselves actively doing harm to themselves, that's another question. What's the male, female split in BPD? So, that's another thing that's changed over time. It was long thought to be a female disorder, and there's all sorts of reasons for that. A lot of them are sexist. Now we see more studies that indicate that there are roughly equivalent rates among men and women.

However, there's still a bias, a diagnostic bias for tending to diagnose women, more often as BPD intending not to diagnose men with BPD. So does that mean under diagnosing men over diagnosing women potentially? I think so. I think the under diagnosing of men has been shown in a number of studies. And it appears that men have to be more severe in order to receive the diagnosis than women. Whether women are overdiagnosed, I'm not sure, but I think it's very rare that you would see a psychiatrist or a medical professional do a diagnostic assessment. I think it's much more likely that they base that diagnosis on,

is this person difficult in some way? So when you look at the twin concordant studies of things ranging from autism to depression, you see a very strong genetic component to these things. Do you have a sense of how strong the genetic link is for BPD, presumably based on these identical twin discordance studies identical twins raised separately and looking at the prevalence how much of this is genetic and then how much of this is environmental where life events Trigger a susceptible individual to manifest the traits So I don't know the data off the top of my head about the twin concordance

But I would say there's a general understanding that there is, of course, a genetic component to this disorder. And I would say that the DBT framework is one that has a model for explaining how BPD develops, which we can probably get into, but that speaks to the fact that there is both a genetic and an environmental component to the development of the disorder. So let's go back to Marsha and her journey. So she has this, you know, literally come to Jesus, right? So she has this kind of epiphany in her late teens or early 20s, which it sounds like puts her on a different path, potentially saves her life. It's still a long way from there to where we are today. So walk us through that journey. So this is where it picks up in terms of the story that is part of the development of

DBT's story. Now leaving out her own personal history, you know, Marsha went on to get a degree. I should also point out that I think one of the factors that led to Marsha being able to do this is that I think she's hands down a genius. And so that was probably despite her really difficult experiences. She had this amazing capacity that helped her. I'm sure in numerous ways including developing this treatment. But so she went on to get a degree in social psychology, a social psychology PhD, which is a little known fact about her that she doesn't have a degree in clinical psychology, but she got her social psychology degree, but then decided that she wanted to get clinical training.

And that's what led her to this training experience at Stony Brook, which is where they were doing a lot of work on theory and treatment related to cognitive behavioral treatments for a range of disorders. And at that time, nobody was studying cognitive behavioral treatment for suicidal populations. And so Marcia decided, suicidal populations. And so Marcia decided, I want to take what we know about CBT that seems to be hugely effective for all of these disorders and I want to take all that we know about CBT and just plop it into treating chronically suicidal individuals. The way she reports it is saying she wasn't interested at that time in diagnosis. She just wanted to work with people who chronically experienced urges to die. That's what she attempted to do and by her accounts this quickly blew up.

Just for timing, this is now the early 80s. Yes. Late 70s, early 80s when she did her fellowship there. And do we have a sense of how she is treating herself at this point? In other words, how is she regulating her own emotions? Are the tools of CBT things that she is finding helpful for her own self-care? This is a great question and I'm not sure I know what the answer is and what's interesting is that I think that what Marcia did was she took a lot of her own experiences and then she was able to translate that into cognitive behavioral terms, which led to the development of a lot of the skills in DBT that she developed for people, whether she was thinking at the time about applying CBT to herself, I don't know, but I think that that's what she ended up doing by developing these skills.

She sort of became the index case, right? She was not necessarily thinking it of this way, but she was working out the tools of how do you transition? I sort of liken that to what Bruce leaded. I don't know how familiar I'd Bruce lead, but most people sort of know him as kind of a movie star in martial arts, but he was far more relevant in creating a system of martial arts called Jit Kundoh,

which took from over 30 different other styles of martial arts and in his words took what was useful and discarded what was useless and created a new system with a very particular goal, by the way, so you had a very clear objective in what you'd condo is to be about. And in some ways, it's almost like that's what Marsha was doing on herself. Yes, on herself and also in her treatment development work, which is very iterative process, like let me try this.

Does this work? I'll keep it. Does it not work? I'll throw it out. If it works, what is it? How do I define it? How do I write about it in a way that other people can do it and put it all together in a package? Again, I think this speaks to Elk Brilliant. I think she is that she could do it, but it does align with what you're describing, which is and what's I think really exciting about treatment development work is this whole process of figuring it out as you go, and then trying to replicate it, and really using the client's experience to say,

is this having the intended effect? So I interrupted you, but let's go back to Marsha at Stony Brook and finding out that CBT in its current form is not helping suicidal patients, at least not to a level that she's feeling is successful, right? Right. So what she, again, this is second hand, so I just tell the story as though I'm her, but what she would report is, okay, I go into my session with somebody and I ask them about what are all the problems that you're experiencing that is causing you to feel suicidal and a person would say, I hate my job, you know, I hate my relationships, I don't have any pleasure in my life, whatever those things are, and Marsha with the CBT lens would say, we can figure this all out. We'll just take all of your problems. We'll put them on a list.

We'll systematically go through each of your problem, one by one, which we'll solve. We'll figure this out in no time. And the way she reports it is that she did that feeling all the hope in the world and the reaction that she got was totally unexpected, which is people saying, you have no idea. You have no idea how bad my problems are.

If you thought that these are things that are easy to solve, you are sorely misunderstanding the depths of my problem. You clearly don't understand anything about me or my situation if you think that these are things that could be easily solved. More than that, if these were easily solved, I would have solved them a long time ago. You have no idea how much I'm suffering, right? You don't get it. So this iterative process was like, okay, this blew up. This isn't working the way I intended. And so the next piece of her story is she would say, okay, that's not working. I need to figure out what's going to work. She took the other perspective and she said, okay,

what they're telling me is that I don't understand the depths of their problems and maybe that's true. And so what I need to do now is tell them and work with them to completely understand. And so she would go into her sessions with people who are chronically suicidal and say, you're right, your problems are too difficult. You've had longstanding experiences with trauma. You've been treated terribly your whole life. You have a number of obstacles that may prevent you from getting the job that you want or the relationship that you want. And perhaps what we need to do is work on accepting your life as it is and finding joy in that, but, the life as you have it and like go of trying to solve all these problems. And so that was her next step. And this is the epiphany that,

of course, anyone who's done DBT knows is radical acceptance. Well, it wasn't quite labeled that yet. What she would, was this kind of the precursor of what we would now describe as? Yes, I think it could be the precursor, but it was missing something because what she would say is this is the acceptance piece. But when she tried it thinking, oh, this is what people want. You know, they're saying, I can't solve their problems. And so clearly, if I communicate that I understand how difficult things are and we can work on accepting it, the reaction she got then was what?

There's no hope. How can you say that I should just accept this? My life is miserable as it currently is. If I accept this, there's no hope. I should just die. Again, you don't possibly understand everything. DBT stands for dialectical behavior therapy. We can talk about dialectics,

but this is what turned into the idea of this primary dialectic in this treatment, which is the dialectic between change and acceptance. And figuring out how do I as a therapist, as a treatment provider, straddle this line, synthesize this because both of these are important. We need to work on solving

the problems in your life that are causing you such distress and misery. And we also need to work on accepting your life as it is and accepting the things that we can't change about our lives. But how do we do that in a way that is palatable to the person on the other end, and in a way that conveys hope that things could change. And so it's about synthesizing those two elements. And I think it's the synthesis of those elements that lead to things like radical acceptance and other components of the treatment. So this is probably a great time to double click on what dialectical means because I'm not sure if it's innate to us. I think it requires some practice.

I was listening to some interview the other day where somebody just simply said, humans don't like contradiction. That's true. We don't like contradiction. And so dialectics is really, by the way, I'm no expert in dialectical philosophy, as Marks initially wrote about it. I'm more a student of dialectics as it informs my life and my practice, but dialectics is this understanding that there is contradiction and opposition and tension in everything. And therefore, we can't avoid it. And the more we try to avoid conflict

attention, the more likely it is that we're going to see conflict attention. So dialectics, at least, again, in the practice of DBT, is the practice of recognizing tensions as they exist, polarization polarization as it comes up, and then striving to find what is valid about both sides or both sides of the tension and seeking to find synthesis. Some new argument or new statement that recognizes and adopts the validity in the two opposing sides. A reasonable time to jump forward and then I want to come back because I love this story, but

if a person listening to this or watching this has ever kind of gone through DBT, then they're familiar with the workbook. You're doing this in a very structured way. And one of the first images in the workbook is the two intersecting circles of One of the first images in the workbook is the two intersecting circles of wise mind and emotional mind. Emotional mind and reasonable mind. Sorry, reasonable mind. Yeah, wise mind being the intersection. Can we use that as an example of dialectical synthesis where you have those two

minds intersecting and then that union or intersection of them being the wise mind and how do we find those? Again, contrasting it with emotional and reasonable mind? That's exactly right. That is an illustration, a key illustration of dialectics at play is this notion of wise mind and wise mind being a skill in the workbook that we teach people as something that we are striving

to access wise mind more often in our lives, and that accessing wise mind involves synthesizing these two tensions potentially, or polarization known as emotion mind and reasonable mind. Emotion mind is the idea that a state in which we are completely controlled by our emotions. So when we're angry, it could be lashing out at somebody, it could be engaging in physical violence, it could be threatening physical violence, it could be slamming doors, could be quitting things, you know, all the things that we might do when we're being controlled by the anger we're experiencing. Reasonable mind, on the other hand, is when we're being controlled by the anger we're experiencing. Reasonable mind, on the other hand, is when we're controlled kind of by facts and logic,

we're not aware of or experiencing an a-strong emotion. You could imagine or you can envision the tension that exists between these two. If you've ever been in a motion mind, having an argument with somebody in a reasonable mind, or vice versa, because that happens a lot, I think it has happened in my marriage. It probably happens a lot across many people's marriages, where one person is in a motion mind, the other person is in a reasonable mind, and that's a recipe for a really strong conflict. So, why is mind saying, what's valid about the emotion

that I'm experiencing here? What's valid about reasonable mind that I'm experiencing here and what's a synthesis? So, a silly story that we might tell to illustrate wise mind or emotion mind is, you're walking down the street and you pass by a pet store and in the window are a dozen puppies. Or if you're a cat person, imagine a dozen kittens, okay? A motion mind takes over and says, I want all the puppies. Every single one of them because this one is cute for this reason,

this one is cute for this other reason. Oh my God, they would be so happy together and I would be so happy if I had all these puppies in my life. I want them. So emotion mind says, get all the puppies. Reasonable mind says, Oh my gosh, dogs are so much work. You have to walk them three times a day. They're expensive. You have to get all this

equipment. You have to get a veterinarian. You have to restructure your time so that you spend more time with the dogs or not. You have to reimagine your whole life around that. So reasonable mind might say, no puppies, puppies are never for you. So what does wise mind say? Well, what's great about even teaching this as an idea is that wise mind is not a synthesis, dialectical synthesis, is not a compromise. It's not a halfway point, because if I were to say that, then wise mind would say, get six of the puppies

if there are 12. And that makes no sense as a compromise or as a synthesis because it's not seeing the validity in both sides. So what would wise mind be? That would vary depending on the person because for some people, a wise mind decision would be to bring home a puppy. For other people, a wise mind decision would be to say, now is not the right time for me to have a puppy. For other people, a wisemine decision would be to say,

now is not the right time for me to have a puppy, but I'm going to do X, Y, and Z in order to increase the likelihood that I can have a puppy in the future. Wisemine might be, I have the perfect scenario now, I can bring home two puppies and we will live happily ever after. So it's going to vary, but the idea of finding this synthesis is about seeing what's valid and true, about both of the sides and then trying to figure out what a synthesis could be. One of the things I'm struck by when I look at the notebook, the workbook that we use in DBT is how much is in it. To think that this is the work of largely one individual, and obviously it's been iterated on,

but can we go back to the story of some of the earliest insights she had treating some of the most in need patients and how she basically then realized she couldn't do what she was doing under the umbrella of CBT and needed to make this change from the cognitive to the dialectical and create another form of behavioral therapy. You know, getting back to where she was in terms of realizing that if I push for change

to hard disaster happens, if I push for acceptance, two-hard disaster happens. What can I do to find the middle? How do I balance these two things? Again, part of the lore of the story of DBT was that she was writing about this idea of balancing change and acceptance. And these were the days where she would write up notes, either handwritten or on a typewriter and hand them over to a secretary who would type them up or revise them. Her story is that her assistant

that was working on typing this all up came to her one day and said, my husband is graduate student in philosophy. We were looking at this and we think that what you're describing actually is something that he studies and is called dialectics. So according to Marcia, she didn't know anything about dialectical philosophy as she was iterating this treatment. And this was one of those happenstance moments that came to her. And then then of course she sought out readings

descriptions of dialectical philosophy and saw, yes, that is exactly what she's thinking and that dialectical philosophy informs a lot of science and scientific thought and so actually worked well within the paradigm of the development of cognitive behavioral treatments. So that's where DBT started to take form. If you're familiar with her books, you know that her original treatment manual that was published in 1993, and also the original skills workbook that was published in 1993 says on the cover cognitive behavioral therapy for borderline personality disorder. Well, I wasn't aware of that.

Yeah, the newer edition says dialectical because she was told at the time by the publisher is that nobody will know what this means and nobody will want it. That may be true. It's possible that if it was called dialectical behavior therapy on the cover of the book, back then, it would not have actually been as popular as it is now. Now, of course, we can put dialectical behavior therapy on the cover of any book. And people will see the practice of mindfulness, which also is a very important muscle that one develops as they move along their DBT journey? Was this something that had been more long-standing with her? I think that this was all happening around at the same time. Marsha grew up in a Catholic family identified as a very religious person, identified as saying that at one point she thought she was going to become a nun. And so this was a large part of her upbringing. Also was part of that spiritual experience that she had personally. And another reason, by the way,

that she didn't wanna come public with her story early on is that she didn't want the lesson to be, oh, if you wanna get better, you also have to have a spiritual experience. Instead, what she wanted to figure out was, how do I operationalize for lack of a better word? This spiritual experience so that other people could experience it as well?

That was going on in her mind, at the same time that she was interested in her own spiritual development and learned more about Zen and became a student of Zen Buddhism and saw that they connected and came together because ultimately how she translated that personal experience is into this idea that you mentioned earlier of radical acceptance. Can you radically accept this moment, this situation, yourself, exactly as it is. And if you can experience that radical and complete and total acceptance,

you can experience joy. You can crack open the moment of joy, you would say. There are some things where, like you're stuck in traffic, you're supposed to be going somewhere, and let's pretend it's someplace that matters. It's not just like a dinner reservation. Let's say it's your kids sporting event or you go into the airport and it's a flight

and if you miss it, it's gonna really wreck things up. And there's nothing you can do about it. You're stuck in traffic, there's an accident a mile ahead and this is the way it's going to be. Your patient now is in the car and you're sitting with them in the car, understandably getting very flustered at the situation Walk me through radical acceptance in that situation. How are you helping that person?

Go through the you know, can you fix this problem? Are you accepting this problem going through all of those layers for that specific type of problem? Yes, and I've been in that problem myself. So I understand. Yeah. What I would say as a precursor is that when we're experiencing suffering, however you define that suffering, if you were to look at it more deeply, you would say the vast majority of the time that we're experiencing suffering, it's because we're thinking about something that has already happened, verminating, wishing it hadn't happened, mulling something over, whatever it might be, or you're thinking about something that may happen in the future.

And that actually, if you just experienced this one moment and let go of the past and the future, that alone might reduce your suffering a ton. But we could say you might experience pain in this moment because this moment might be painful, but we're not adding on. We're not adding on all of these things that actually increase our suffering. So in this moment, when you are stuck in traffic, you can't undo the decisions that you made that got you to this point. Because, of course, we're saying things like, oh, if only I had taken this other road, or if only I had left 15 minutes early, or we think all these stupid people on the road, if only I had left 15 minutes early or we think all these stupid people on the road,

if only they had done something different. Those are all fantasy thoughts because they're all not reality of this moment. So I would say how do we reduce our suffering in this moment is to say I can't change any of that for today in this moment. This is what it is. What happens, you'll see actually, I'm holding my palms up right now as I'm talking because I associate, holding my palms up with this idea

of willingly accepting this moment, which is this is the moment that I'm in. Yeah, it's sort of a surrender posture. Yeah, in a way, it's the surrendering, willing, this is the moment I'm in. Yeah, it's sort of a surrender posture. Yeah, in a way, it's the surrendering, willing, this is the moment I'm in. And what happens if I just just, as though it's easy, but what happens if I accept that right now, there is nothing I can do to change this.

Now, I think the other piece to this is, and this is why it's not just about acceptance because I would say, if this is something that happens a lot, right, if you often find yourself in situations, whether it's traffic, running late or something like that, then we absolutely want to figure out how to prevent this from happening as much in the future. But in this moment when you're there, you can't do that. In other words, in the moment of crisis,

you don't really want to be problem solving around, how can I avoid this the next time? How do I avoid this crisis again in the future? When I'm at a 100 or a 90 of distress, I'm not going to be able to effectively do that. Now, obviously, so much of what you're saying sounds very familiar to anybody who has practiced mindfulness or the pass and are one of its derivatives in forms of meditation. We've had a couple of podcasts that have gone into that and the goal of the practice is to help you identify thoughts and to separate you from these thoughts.

There's probably nothing as you say in this exact moment that is particularly unbearable, but the thoughts are unbearable if you let them go. I'm going to get to the airport and I'm going to miss my flight. Then I'm going to have to wait for another flight and I'm probably going to miss that too or there not going to be a good seat or whatever. And then I'm going to not get to where I'm going. And maybe the whole trip is going to be like, and so what do you say to the person who says, okay, Shereen, I understand that those thoughts, which are all future, are not happening to me now. And I can just sit here right now in this car. And frankly, I could turn on music

and enjoy the music for the moment. But that doesn't change the fact that that's going to happen. It doesn't change the fact that in an hour, I am going to get to the airport. I am going to have missed my flight. What do you say to the person when they acknowledge that I could probably take myself down from 100 to 50 by being present in the moment?

But will I get back to 100 when I get to the airport when I realize that I now have to deal with this mess? Possibly, but that I get back to 100 when I get to the airport when I realize that I now have to deal with this mess? Possibly, but that's a new moment. Now you're in a new moment and a new situation. So part of it depends on, well, what's your goal? So when you're experiencing distress in that moment of being stuck in traffic and not having any control about that, what's your goal?

If it's to get to the airport in two minutes, sorry, that's not a realistic goal. We're gonna have to let that one go. If it's to problem solve what will happen when you get to the airport, is there something that you can do while you're in the car? Possibly.

But if your goal is to, how do I make this moment more bearable because I can't undo anything, then I think we have some other options available to us, which could be distracting, you know, doing something like music or some other forms of distraction that you could safely do in the context of your car. So now let's look at the other end of the spectrum

where I think it becomes even harder to do this. So I think of two examples. I think of an individual who receives a terminal diagnosis. They're diagnosed with a cancer, for example, that let's make this even more tragic, right? I think anybody dying of cancer is tragic. But now it's someone your age or my age, who's dying decades too soon

But they're basically told and it's accurate that look in six months. You're not gonna be alive So in that sense they're mourning the loss of their life and who they're going to be away from and then there's another example Which is very fresh in my mind right now because very close friend of my wife's daughter drowned a year ago Because we're coming up to the one-year anniversary of that, she's reliving a lot of this. It's hard for me to imagine what she's going through and what her husband is going through, but there's nothing that will undo that. No.

Maybe use those two examples as two of the most difficult examples of how can radical acceptance allow, hey, this person who's going to die far too soon to come to grips with that and maybe have a chance at having the best six months that they can have versus not. And then perhaps even more tragically the parent losing a child, you would sort of hold that up as about as tragic as anything can go where nothing is ever going to bring that child back. And yes, cognitively, you can say, look, you still have other children, and you have to be a great parent for them. You can't allow yourself to, like, I don't know how I

would cope with that. I don't think I could. I'm not sure. So now let's go from the sort of banal of traffic to the really heavy stuff of life. Easy, right? So I've thought about both of these things a lot or both of these circumstances, a lot. One of the misunderstandings about acceptance is somehow this idea that if you accept something you don't experience pain. And so I want to differentiate that life is full of pain, no matter how zen and mindful you are, you're going to experience pain and a lot of pain. And we're not trying to eradicate pain because actually without pain, and I don't mean physical pain, I mean emotional pain, but it could be both. But without that, we would have other problems. If we did not experience pain as you hear about your friend's daughter, that would be a problem for you in a different way. We need to understand that pain is going to be a part of our lives and actually because a lot

of problems for ourselves when we try to escape the experience of pain. So that's one thing about reality, radical acceptance that I want to talk about. But the other is when you ask questions like that, like how can we ask somebody to radically accept this? I would answer in part by saying, what's the alternative? The alternative is refusing to accept. How does that work? How do you do that? And how long, how does that work? How do you do that? And how long can you sustain that for?

So I would actually argue that the refusal to accept or the putting your head in the sand or the denying reality actually ends up taking a lot more mental resource and ultimately causing more problems for you in the long run. That said, from a DBT perspective, when we talk about practicing the skill of radical acceptance, we have another expression called turning the mind, which is referring to the fact that practicing radical acceptance involves a very active process of continuously turning your mind towards acceptance. The metaphor is that you're at a fork in the road and one road is acceptance and another

road is refusal to accept. You're going to come across the fork in the road, possibly multiple times a minute. And what does it look like for you to say, I'm going to actively and willingly choose the road of radical acceptance? How can I turn my mind, my body, my soul towards acceptance? And for me, a lot of it is actually asking myself that question of what's the alternative? What other choices do I have? And recognizing that more suffering comes from refusing to accept more often. The fact that it's referred to as radical acceptance versus acceptance, I think kind of highlights

that it's not easy. It's not like you would sit down with my wife's friend, have this discussion once, say, what's the alternative? I know this is awful, but in the long run, this is going to produce more happiness for you and your family. And for her to say, yep, I think that's right. Thanks. No, it's not. It's to your point, every minute of every day for God knows how many months and years you're confronted with that.

And if I speak for myself, there's a lot of backsliding. There's a lot of, no, I don't want to accept this today. I don't accept this. I'm angry about this. I want to pout and have a little pity party about this. And then maybe I experienced that and I realized that wasn't very productive because now I feel actually worse. You know, we were introduced through Andy White, which is who I work with, and I just think the world of Andy. One of the things about DBT that for me makes it a wonderful system is that you do work, you write,

you have homework, you have to write out your emotions and your decisions and the trees. If you feel this, do you do this? And how deliberate was that in Marsha's mind as a system? I've never done CBT, so I don't know if CBT has a similar workbook and she's just modifying it. Is that something that's been modified from other systems? Certainly CBT is associated with doing homework, doing work in between sessions. More standard

cognitive therapy is associated with doing worksheets about your thoughts, what thoughts you have, what the evidence for your thoughts are, that sort of thing. Doing work, doing work sheets, not shying away from the term homework as part of the treatment is very consistent with the CBT model. What I will say is,

you just remind me about this based on something you said is that one of the assumptions about borderline personality disorder from the DBT lens is that we use a skills deficit model, which is to say that we believe that people who end up with the constellation of problems associated with borderline personality disorder have an absence of certain skills in skillful behavior in their lives, and that absence could be a result of never having been taught it in the first place, or having had effective behaviors been punished out of them by their environment. This is the environmental piece that we're talking about, but they don't have, we all have certain deficits in some skillful areas.

And another one I would just add to that is the skills have never been modeled for you. You've done them correctly and been punished for them. I think a bigger one might be you've done them incorrectly and never been corrected. Yeah, that's a good one too. So you've built all the muscle memory doing it wrong your whole life and you didn't have parents there to say, Hey, that's not how you do it. Right. Do it this way. And it's a lot harder to unlearn a behavior than it is to learn a new behavior. We know that as a phenomenon.

Marsha developed this book. We refer to as the skills training manual, that's part of the treatment of DBT. And perhaps what DBT is probably most known for more broadly speaking are the skills that are part of it, but that these skills deficits are thought to exist in four different domains or five different domains, actually. Mindfulness. So when we say someone has a deficit in mindfulness, it's not that we're referring to anybody who doesn't practice Zen is having a mindfulness deficit, but it's a deficit, the capacity to be aware of the present moment, basically. Another domain in which people have deficits is interpersonal effectiveness. As I go through this, you'll see everybody has deficits in all of these areas at different times. And I think, again, that's part of the beauty of DBT

is that it can help so many people. So interpersonal effectiveness, which could mean conflict with others, but also could mean deficits in knowing how to ask for something effectively, how to say no effectively, emotion regulation deficits is the third domain, deficits in knowing how to label your emotions, what to do with emotions, when you have them, how to prevent having intense and extreme emotions, how to change emotions. Can't

remember if I said that. And then a fourth domain is deficits in distressed tolerance. How do you tolerate really stressful and distressing situations without doing anything to make the situation worse. And then the fifth area that is not talked about as much as I can certainly talk about it, if that'd be helpful, is this idea of self-management, deficits in self-management, which has to do with being able to do things you don't want to do, probably speaking how some people can get up every morning at six o'clock and go exercise and eat a healthy breakfast and go to work while other people snooze their alarm eight to 12 times, have hazardly eat breakfast sometimes, get to work late. Those are sorts of things that we might say fall into this kind of self-management domain.

And so DBT is designed as a treatment package to teach people the skills to overcome deficits in these different domains. I actually wasn't aware of the fifth. I was really only aware of the four. Is that fifth one kind of a more recent addition? Is that fifth one kind of a more recent addition? No, it's actually in the original treatment manual in the 1993 text that she put out, but her thinking was, I don't need to create a whole other skills module for self-management because DBT therapists are going to infuse this throughout their entire treatment. And I think this might have been, at the time time a little bit of a missed opportunity because I don't think she realized that actually a lot of clinicians don't know how to do that very well. Marcia was thinking that actually this is where behaviorism comes in.

It's teaching people principles of behaviorism. So you don't see it in the original skills manual and you don't necessarily see it in the new skills manual or what I refer to as the new skills manual unless you don't necessarily see it in the new skills manual or what I refer to as the new skills manual unless you look because where you would see it now is in the set of skills that are referred to as the walking the middle path skills, which actually came out of the first adaptation of DBT for adolescents and their families. And Jill Rathas and Alec Miller, who along with Marsha created the adolescent version of DBT, took a lot of these principles of the self-management skills and created this fifth module of DBT skills

called Walking the Middle Path, in which they teach adolescents and their caregivers, their parents, these skills about how to manage your behaviors, how to learn behaviors, and to be more effective, more broadly. Just going back to the origin of DBT around a modified tool to help some of the people who are suffering the absolute most. You think somewhere in the back of Marsh's mind, it probably wasn't just, the absolute most. You think somewhere in the back of Marsha's mind, it probably wasn't just, how do I make CBT better to handle the most recalcitrant depression, suicidal patients?

Perhaps on some level, it was also BPD. We kind of glossed over this, but I'm guessing that CBT has historically not been very successful for borderline personality disorder. Is that a fair statement? Well, I would say at the time that Marsha was doing this treatment development, we didn't know. The general thought, and there actually, there have been more studies that have looked at whether the presence of borderline personality disorder interfered with outcomes for standard CBT.

And there's kind of mixed data on that and that some studies show that the presence of BPD did lead to worse outcomes in some studies. But what I was going to say is that Martian didn't know the reason that she gives for her pivot to borderline personality disorder as a population of interest is that when she was first seeking research dollars, research grants to study the development of DBT and, you know, to start

to do randomized clinical trials of DBT rather. Back in those days, you could only get research grants from NIH if you identified a disorder of interest. The way she tells it as oversimplified is that she was interested in suicide and suicidal behaviors. And at the time, she thought her choices, based on that behavior, was either depression or BPD. And she said at the time she didn't want to do depression because there were already so many smart people doing depression research. She wanted to go into an area where

there weren't already a lot of people doing research in this area. And that's why she chose BPD. Again, this is the story, but of course, I think there's more to it than that because her own experiences would lead one to assume that she also had specific interest in the emotion dysregulation piece that goes along with BPD And doesn't necessarily go along with more standard depression So what would you say? I know what I would say, but what would you say to somebody who doesn't have BPD? It's not depressed who says, you know, Peter Schrin, this is all very interesting. But would there ever be any benefit in me doing DBT given that this program was really built around people with real pathology of which I have

none. I went through the DSM five last week. I don't meet the criteria for anything fully. Would there be any value to me in this type of practice? I think that's part of what's so fascinating about this treatment because you're exactly right. This was the treatment that was developed for what could have been termed the worst of the worst at the time. And it's a treatment that is actually for all of us. I have yet to meet a person who cannot benefit from at least learning some of the skills, I have yet to meet a person who cannot benefit from at least learning some of the skills. I've yet to meet a person who hasn't identified the skills

as being something that could be relevant for them. Now whether they're always willing to use them or apply them or want to do them, that's a different issue, but when I talk about here's what the skills are for. I get universal agreement that those skills could be useful to learn. You don't know this about me, but I love cars and race cars and all sorts of things like that. And a lot of people say, like, I don't really understand how there's any value in a company like Mercedes or any of these companies participating in building race cars.

It's such an expensive proposition. It seems so gratuitous. But the trickle-down effect for what the impact of that is on street cars is remarkable in terms of fuel efficiency, power, safety, all of these things. It's true. If you want to build a formula, one car, it's basically a $400 million a year operation to build and operate those things. But those things are functioning at the absolute limit where every gram matters and the stakes are so high. And if you take everything that you learn there and bring it down to the rest of us who aren't driving formula one cars, the benefit is actually enormous. And I think of it as sort of similar, right, which is this is a system that was conceived and validated on a sample set of people with real difficulties in regulating their emotions.

You know, when I go through the list of the BBT skills pillars, it's like, check, check, check, check, check. I might not meet the diagnostic criteria for something in the DSM-5, but I have enormous problems with all of these things. I have staggering deficits of skills. I mean, one of the first exercises that really illustrated that was something as simple as identification of emotion. You know, it was any emotion that...

I wouldn't say that that's simple necessarily, but... Yeah, yeah, yeah. But it was like, I couldn't really identify an emotion that wasn't anger. It was very difficult to go beyond anger to helplessness, sadness, hurt, fear, all of these other things. Andy and I must have spent three months with my homework just being, okay, you're going to get angry 16 times a day, 16 times a day, pull out this sheet and go through and figure out what else is going on. That sounds maybe simple, but that's learning a new language as well. What made you want to do that? Why not just stick with your experience of anger?

It's exactly what you said earlier. It's like, what's the alternative? All the alternative is you're really alienating a lot of people. And I think watching my kids get older and realizing, I don't want them to see me, you know, I think I was just angry 24-7. I don't think I really experienced anything that wasn't anger. So, who's just saying, like, I have to sort of break this cycle because if every time I get cut off on the road, I'm screaming so much at the person who cut me off that you can see the droplets of my spit on the windshield. Even if I'm not yelling at them, it's not like I was actually yelling at my kids.

Because I've learned since I don't think kids can appreciate the difference. A five year old doesn't understand that just because daddy is yelling at the guy that cut him off, he's not mad at me. So I think once I came to realize that, I realized, no, I don't want to do this. So I don't actually have my own experiences with borderline personality disorder or psychopathology in that way. And I learned DBT as a grad student

in my early 20s. And it's been a long time now that I've been using and applying DBT. And I will still go in my head like when I have a difficult interpersonal situation happening where I will walk through the steps in my mind of the dear man's skill of how to ask for something and be effective. Let's go through dear man in a moment.

Finish your story, but I would love to go through it. It's been 25 years, and I'll still be writing an email, and then I'll say, wait, pause, edit. Am I following the DEAR structure? What can I take out? What am I adding on? What judgments are in here? So I feel like, you know,

I've been a pretty skillful person for most of my life, and I still benefit from actively thinking about using these skills in my daily 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 always employing them, one out of 10 is not even knowing what a skill is. I'm in the sort of three to four out of 10 range,

which is I know them and half the time I reach for them, but correctly, but let's talk about deer man because everything in DBT is really built around being highly accessible. It's not really, at least to me, it doesn't come across as having heirs. It's funny acronyms. It's like little diagrams.

There's nobody that can't do this. So tell everybody what deer man is and what the acronym is really used to walk you through as a thought process. I think sometimes people actually have a negative reaction to all the acronyms in DBT. And I think that's a fair criticism, but acronyms are meant as nomonics

to help us remember things. Maybe because I went to medical school, we just, you do so much through that. Yeah, yeah, yeah. Yeah, though, I will say I was training DBT somewhere. Where was I? I think it was Iceland where they don't do acronyms. Like it's just not part of their language to use acronyms.

And so that is added difficulty. But in the US and Canada, and we can talk about these acronyms. So dear man is a skill that's in the interpersonal effectiveness module. So these are the skills that are designed to help you be more effective with other people in your life. And dear man is specifically the skill on how to ask

for something in a way that gets another person to give it to you or how to say no to something in a way that gets the person to give it to you, or how to say no to something in a way that gets the other person to accept your no, or increases the likelihood I should say, because nothing is going to be 100% effective. So, dear man, walks you through these seven subskills to help you do that. It stands for describe express assert reinforced. That's the DEAR part. That's basically what you say or write to ask for something. And then the man stands for mindful, appear confident and negotiate or be willing to negotiate. So that when you're in a situation, so I don't know, do you have a situation that is coming up for you where you need to ask for something or say

notice something? Yeah, I do actually. I don't think I can talk about it publicly, unfortunately. It's such a very good one, but I probably can't talk about it publicly. Let me think of one where I could without embarrassing someone. Okay, this is gonna embarrass the hell out of her, but let's try it. My daughter wants to get a third earring, so she's got two piercings in her ears and she really wants to now get a third. Maybe this isn't a great example,

but I'm hoping to talk her out of it for a little longer. How's that? I'm like, why don't you wait till you're a little bit older? I just have this fear that she's going to damage her ears and have so many things hanging that way will stretch her ear lobes out and she'll be 50 years old like me one day and regret it potentially a totally irrational fear, but that's the fear I have So the ask that you want to say is will you postpone this decision for a while or will you take this off the table for a period of time? for a while, or will you take this off the table for a period of time? Someone listening to this might say,

what kind of lousy parent are you? Just assert it. But her mom is not opposed to it. Her mom's like, I think it's reasonable for her to get it. So now it's become more of a negotiation. And how old is she? She's 13. So if you were to practice the dear man,

the first step would be to describe the situation without adding on any interpretations or judgment. If I were your daughter, you would say to me, Olivia, I understand that you want to now get a third hearing. Great. So often this means exactly what you did, which is to keep it short. Because sometimes we have a tendency to go on and on and on about all of our reasons for something, but actually the more we do that, the more we lose the other person's interest. And then express would be to express your feelings about it. I have some fear about you getting a third earring because I worry that it would damage your ears and this would be something that would bother you many years from now.

We could work on simplifying or shortening or saying, I fear is that you would regret this if you did it, whatever it might be, to get the express. But that was also really nice because you didn't add on judgments. You didn't say, you shouldn't do this, right? These are all just describe the facts and then express your feelings about it. Now assert is where you ask for, that's the A, where you ask for directly what it is that you want. Olivia, would you be fine if we could postpone this decision until you're older, maybe even out of high school?

So you may think about prior to doing it, what is it specifically that you're asking for? So if you want to start out by asking, would you be willing to postpone this decision until after high school? Might be a more direct assert, but it could be there's other factors that might contribute to you asking it more tentatively or more firmly. Now, what we often say about this, you didn't illustrate this, but what we often say about this A part that asserts is that a lot of the time we don't actually assert, we just want somebody else to read our minds or do what we want. And I think this is

especially a problem for not to over generalize, but I think women have more trouble with this on average than men, loads of reasons for that, but actually asking directly for what it is that you want is really challenging for people. And so what instead you would see people doing is just doing the describe and express, and then expecting the other person to just know what it is they want and do it. So we're trying to get people to learn how to be more comfortable with asking and stating directly what it is that you want. And then the R stands for reinforce, which is to say,

you want to say explicitly what's in it for the other person, what reward could come their way by giving in into your request or giving you what you want, which in a second we can talk about whether or not this is manipulation, but in the moment in your dialogue with Olivia, what's something that you could imagine reinforcing? You play volleyball, you're really good at volleyball, you're playing year round now,

and the more jewelry you have on the greater your risk of injury, you get hit in the head with a ball. That's one more thing that could hurt. This is just one less thing to worry about, right? That would be one sort of very narrow niche approach. Probably my preferred way would be something like optionality is a great thing. And by not doing it now, it doesn't mean that you can't do it tomorrow. You always have that option, but you can't undo it once you have it. Now she'll argue, yes, you can, you can just take it out. So I don't know, maybe she's right, but those would be the things I would reinforce, which is, I'm not saying no, I'm just saying not

now. And that really isn't taking anything away. It's just potentially delaying something. I agree with you about all of those points. What you're doing is you're providing more evidence in favor of what it is that you're asking for. But if I were to think about reinforcing in the sense of what reward could she expect if she were to say, yes, dad, I won't get another piercing. Could you think about something? So is this something where I could literally just say, and if you

don't do this, is it literally like you're bribing your kid? Is that potentially what's in there? It would be bribery, but bribery is what we do all the time. Would it be something like, and if you don't do this, we could go shopping in those new converse shoes you love. Let's get those instead. It could be. Okay. I never thought of it that way. I've always thought of it more theoretical reinforcement. Which I think can work sometimes with some people more often than not. It needs to be a tangible connection to this. Now, what we often say is a good fallback that asking somebody for something at work

or interpersonally is to say, if you do this, I would really appreciate it. My appreciation of you and your behavior is a reinforcer. You might feel good by the fact that I appreciate it. When I see something like what you're describing your daughter wants, her dad's appreciation of not high on the list of things. Exactly. Right. So you have to think about the person that you're asking and what is most likely to work. You also have to think about to certain extent, how important is it for you to get this thing that you're asking for?

And if it's really important for you to get it, then you might say, oh, I don't like buying her sneakers instead. But if that's what worked, then we would say, you know, be effective in this situation. If this was something that was really important to you, there's a meta thing here, which is I'm teaching her by my behavior and my interaction. What is a more emotionally regulated way to handle this? Because the old version of me would have just said, no, I'm the parent, you're doing what I say, this is non-negotiable. And if I was a kid and argued this, I would have got the back of the hand to my face.

So just be lucky you're not getting that for even pushing and provoking this discussion. You know what I mean? So that would have been the old way to have dealt with this. And then she would have run out and gotten the earring and just tried to hide it from you. Right. So now instead we get to model something better. And I assume that that also factors into the DBT for adolescents, which I actually haven't really spent any time looking at that work.

But I would imagine that it's as much about helping the kids as showing the kids how the parents can change as well. So in standard DBT for adults, what we do, we haven't really explained what the therapy looks like, but in general what would happen if somebody were receiving DBT treatment is that they would be coming to a skills training group once a week or receiving skills training individually where they meet with the therapists who teaches them these specific skills. They practice that, they come back, report on their practice and get feedback and coaching, etc. In skills training group, you might have a number of adults altogether and you teach them all together and you assign homework and you all talk about the practice and use of skills.

What was an amazing, just think it's so brilliant adaptation for DBT for adolescents is that in your skills group you have, they're called multifamily skills groups where you have the adolescents in the skills groups but you also have the adolescents parents or caretakers in the skills group at the same time. And everybody is learning the skills altogether. And the way these groups are designed, it's not over all learning these skills so that you all can help your adolescent apply them. Of course, that's part of it. But we're framing the groups as saying, we're teaching everybody the skills because the

parents need the skills as much as the adolescents need the skills, and therefore the parents and caregivers have to practice the skills on themselves, not just for their adolescents. You find it's harder for the parents because you know you said something earlier which I completely agree with. It would almost be easier to come to DBT with no skills, positive or negative, and then just learn the positive skills. It's harder to come in when you have decades of reinforced negative skills, anti-skills, and you have to unlearn

anti-skills and then build positive skills. So, do you see that it's easier for the kids sometimes to pick this up than their parents? Sometimes easier to pick up up than their parents? Sometimes easier to pick up, but there's different levels of willingness and willingness. Yeah, it's their point. So with adolescents, a lot of the times adolescents... They're not necessarily there by choice, I'm guessing sometimes. Yes. So a lot of the times, it's their parents or their schools that say they have to do this.

And so there's always a question of how much they're there because they want to be there. Of course, with adults in certain contexts and situations, they don't want to be there either, but there's generally more willingness. Let's talk about the structure of the therapy. I've jumped around a lot because there's just so many interesting frameworks, and I want to make sure we get to them.

But let's assume that a person comes to you now, and they're there by their own choice. This is an adult and they don't meet the criteria for any of the DSM vibes. So this is just someone who's having difficulty interpersonally. One of the things that I think I sort of realized was so much dysregulation stems

from interpersonal interactions gone bad with your spouse, with your child, with your coworker, with the person who cuts you off on the street. I mean, it's generally an interpersonal interaction that doesn't meet your expectations, whether those are reasonable or not reasonable, that then leads to sort of an emotional regulation, or dysregulation, thoughts that then feed

into those emotional dysregulations, and then you create this awful feed-forward loop that can lead to bad behaviors. From interpersonal to thoughts, emotions thoughts feeding off each other, and then behaviors. I mean, that's kind of like the pathway of how this all seems to go wrong for people.

There are some people out there who seem just wonderful and they don't seem to suffer from these issues, but most people, if we're being really honest with ourselves, even if you're not as extreme as me, I think most people realize that this isn't always going well, especially as we're under more external stress. I love the idea of distress tolerance. I think that's just one of the most interesting concepts is a window, and that's the sort

of image that I have of it. This entire year, my distress tolerance window is about this thick. And it's all my own fault. I've put way too many things on my plate. And so there's no buffer. There's no margin for error. Even before this podcast was recorded, I was getting upset about some stupid video I had to record. I had to record it twice. It was supposed to be two minutes.

The first time I did it, it took two minutes and 20 seconds. Like, something so dumb that shouldn't even bother me, bothered me because I'm out of time. So something like external factors will change your distressed tolerance window. For me, it's always being too close to the top where it's getting upset, but for some people it's being too close to the bottom

and it's getting sort of dysthymic or depressive versus getting irritable. During good times, imagine being on vacation for two weeks. You don't have to worry about email, nothing is going on. You go to a restaurant and they forgot your reservation, you're like, yeah, no problem, we'll go to the next one. I think people can resonate with this idea.

One of the skills is how do you make that distressed tolerance window higher? How do you make it wider? There's nobody that's not gonna benefit from this. It's a long rambling question, but really where I'm going is, you get somebody that comes in. Where do you start? When you just said that, what I was reminded of is learning what makes us more vulnerable to negative emotions or stress or distress, and that is another key skill in DBT is to

identify and understand what our vulnerability factors are and then to address because sometimes we could actually target or treat our vulnerability factors and our lives just go much more smoothly when we sleep decently. You know, when we remove some things from our list so that we're not so stressed all the time, like that could actually solve a number of problems. I'm glad you brought that up because I should have mentioned. That's actually one of the first things Andy asks me. I've been working with him for two years now. It's always once a week. But that's one of the first questions he always asks, which is, tell me what's going on physically?

Are you in pain? Are you sleeping? What are the other vulnerabilities? And I think out of the gate he's trying to gauge what state I'm in as a function of how many things are pressing me. And how in those moments how able are you to receive info? Like if you're at 90 on a scale of zero to 100, you're not taking in a lot. You're not learning a lot. If you're at that level, then we need to figure out how do we get you regulated enough so that you could learn to do something differently. And I think that that's great that he asked those questions.

I think for myself, when I'm in physical pain, I just can't do much of anything. He's had me pay much more attention to those things. If you haven't slept well in two nights, you can't and you shouldn't assume that you're at your best in terms of your ability to receive both information and tolerate things. Physical pain is a very interesting one. I agree with you completely.

I'd love for you to share an example of your own life. I have so many of where I've been in pain and it's made me more irritable. What have you noticed and what do you do about it specifically? I just admire people so much who have chronic pain conditions and function in their lives because I have been fortunate to not, I mean, I've had pain, but to not have a chronic pain condition because I think that would be a challenge for me to learn how to navigate that, but I do think that when I'm experiencing pain and whether it's a transient headache that I know will pass or I hurt my back, you know, exercising and now I feel it every, which way I personally recognize that as a huge vulnerability factor for me because it makes me more irritable in general and makes me

much more likely to snap at people or to have less patience for things. So for me, what that means is recognizing similar to what you said, like, okay, this is going on for me right now. I have to accept this is going on for me right now, because I can't just will away physical pain as much as I want to, and know that this is a vulnerable time for me. So given that it's a vulnerable time for me, is there a way that I can reduce demands on myself in other ways? Or is there a way that I can treat myself kindly in other ways to kind of offset the pain that I'm experiencing? And sometimes for me, it's also

morning to be more explicit and vocal as relates to kind of this interpersonal effectiveness, because when we experience pain, it's often entirely experienced within our bodies. Other people may not even know that this is happening for us. So learning to say out loud and now granted, it helps as your kids get older. You can say things when they're younger. You can't say as easily, mommy has a headache, but they get older and you can say things when they're younger, you can't say, as easily, mommy has a headache. But they get older and you can say, I'm really suffering right now from this headache, so I need to have a little bit of space from this conversation or this situation. So learning to recognize this as a vulnerability factor and then figuring out how can I act more skillfully within this context to prevent the lashing out, to prevent irritability.

Because I don't know if this is your experience, Peter, but mine is that whenever I do act out of anger, I almost always regret it and almost always feel worse about myself afterwards. And so it's almost a selfish process. It's to help the other person by saying, I'm not going to get irritable with my kids. It's to protect them, but it's also to help me not feel so bad afterwards, because my kids will recover. I'll recover, but I don't like how it makes me feel. The cycle of anger and shame and isolation, I know the path well. Yeah. Before we leave the pain thing, one thing I've observed in myself is not all pain is created equal. Expected pain seems to be far less destabilizing to me than unexpected pain. I had shoulder surgery 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 narcotics and things like that. For two days, the pain was so bad I couldn't sleep. I mean, literally I was just sitting up in a chair not sleeping for two nights. But even for that week, the pain was so bad I couldn't sleep. I mean, literally I was just sitting up in a chair not sleeping for two nights. But even for that week, the pain was excruciating. Interestingly, it didn't negatively impact me in terms of interactions, knowing what I know about how much pain can destabilize distressed tolerance, capacity. I would have thought, well, that would have thrown me over the edge. But it didn't because it was like, look, I had six trocars in my shoulder. I just had an enormous operation. This is kind of what it's going to feel like. Whereas I've had headaches that have lasted for three days at a time due to some awful tension and no amount of Tylenol can make

it go away. Ostensibly, it's not as bad as my shoulder was hurting, but one, I don't expect that I don't know why I have it. I find that far more destabilizing to me from an emotional regulation standpoint. I don't know if you've ever observed that. And by the way, I think people with chronic pain, that must be the most frustrating and difficult thing because a lot of those patients are told by physicians, either A, there's nothing we can do or B, this is in your head. And really, you should just kind of ignore this. I 100% agree with you personally and professionally. What I noticed and what you said is that you actually engage

in a lot of self validation with regard to the shoulder surgery, basically saying, of course, I feel this way. It's okay to feel this way. And I think with the other pain that we experience, sometimes we might not realize that we're doing this so explicitly, but we're actually invalidating. Such a great point. We're saying, why am I feeling this way? What's wrong with me?

How could this be happening? Right? And so we're rejecting it. And I have my own personal example. I'm tapering off a medication right now. And I didn't realize when I was prescribed this medication, how difficult, it's known to be a medication that's difficult to get off. And had I known that, it was sort of a moment of weakness that I was prescribed this, I decided to take it, had I known how horrible it would

feel to go off it, I never would have gone on it. But now I'm trying to wean myself off of it. I'm really going kind of nuts with how much I'm like micro-dosing myself on this medication. Because I start to feel this withdrawal symptom. And I'm realizing exactly to this point that you made is that part of the suffering that I'm experiencing about this is my thoughts like, oh, what if this goes on forever? What if this doesn't end?

And even when I realize, okay, it's not gonna last forever, the subsequent thought is, but can I tolerate this for two weeks? Why can't it just go away? And so this is the way in which we do have some control over the suffering that we experience because we're adding on all of these thoughts.

One of the mindfulness tricks that I really love when I hear it, I think I heard it as it relates to like learning to be mindful and accepting of your emotions is just to say to yourself, it's okay to feel this. And it seems so simple, but to say those words, it's okay to feel this, no matter what the this is, can be a really powerful experience. And I think even with the pain, we could say it's okay to feel this and just notice what effect that has on us. So going back to the beginning of the interaction with the clinician and the patient, you start with this idea of what are the interaction with the clinician and the patient, you start

with this idea of what are the vulnerabilities. So once you establish that, and I suspect a lot of that is, you'll see it quicker than the patient will. Like a lot of times people probably don't appreciate what the vulnerabilities are until they're kind of pointed out, which is, no, like these are, again, it's a form of validation. These are really clear things that are going to make it more challenging for you to be understanding of others, to be understanding of yourself, to regulate your emotion, to control your thoughts and ultimately to control your behaviors. So once you establish that, I imagine it's somewhat liberating for people.

It's a nice first way to have you validate things for them. Is that usually received that way? Yes. I think for a lot of people understanding the vulnerability factors and determining ways to reduce their vulnerability is really critical. And you asked me like what I would typically do with somebody who first came in. I mean, I'm used to working only with people who meet criteria for BPD and are usually on that more severe end of the continuum. I don't have experience with people that are not as extreme usually. I think that for a lot of people

learning about vulnerability factors is really important, but I put vulnerability factors in the context of something that we do in DBT called chain analysis, which is a way of assessing problem behaviors that people have that they want to change as a way of assessing it in order to figure out how to change it going forward. So vulnerability factors is an element of that chain analysis. So say, for example, you were in treatment with me and one of the things we were working on as this target behavior of you exploding an anger at various points. We would identify a recent occasion in which that happened. And then we would do an assessment of what were all the factors, events, thoughts, behaviors that led up to that behavior,

and then what were the consequences of that behavior? That would be the chain that we assess as a way of identifying, okay, well, what can we modify in this chain going forward to make it less likely that that problem behavior is going to show up again. I think what we've been talking about is addressing what happens actually very early on in the chain, that vulnerability factor. For some people and in some situations working on the vulnerability factor,

changes everything that follows. But there's other events and circumstances where it's not about the vulnerability factor. The vulnerability factor or the vulnerability factor is just one element, but something happens in the environment, a prompting event, we would call it, perhaps that sets off the chain. And it doesn't matter whether you got sleep or not the night before, because whenever that prompting event happens, you're going to explode and anger, right? So we want to work on vulnerability factors, but we also want to identify, well, what are some other critical elements along the path towards the problem behavior

that we can address and behaviorally manipulate? When you say it that way, it's really obvious because even using myself as an example, which is probably a more extreme example, nothing ever occurs in isolation. Like, I've yet to come up with one example in my life where I can say, I flew off the handle and it was only because of what was happening in that moment. I mean, it's just not the case. If I flew off the handle, this is a situation where I would have barely got upset a day ago or a week from now. It was that literally the six things that had happened, and maybe I didn't have a great sleep. That's not what caused it, of course, but that made me more susceptible.

And maybe this other thing happened, and I didn't deal with it. I didn't confront the person who said such a thing that upset me. And I just sort of buried it and went on. And maybe I read something on social media and I didn't even acknowledge that that was very upsetting to me. And then I find myself in this situation. And I liken it to the challenger blowing up. You remember when the space shuttle challenger blew up?

This is almost 40 years ago now. And I'm an engineer by training. So I really have a keen interest in the ins and outs of that type of scenario. And what you realize is there was nothing sudden about that horrible tragedy. Nothing about that was remotely sudden and unexpected when you actually peel back the layers of the onion and go through the entire chain

analysis for not just the challenger, but all the previous space shuttles. And you realize how inevitable this was. And on that day, this was almost a foregone conclusion. Now imagine watching that as a spectator, oh my gosh, how could that happen? You would get an A on your DBT test because it ties into the dialectical philosophy of everything is caused. Everything has multiple causes. And that is very hard to accept sometimes, and it's also very hard to experience, especially in our dominant culture, that wants us to believe that there are simple answers, and there's one person to blame, or one root cause, that's what the dominant culture is trying to tell us about everything and anything, because that's simple.

And it's more complex than that, that there's always multiple determinants of anything, and that we could dissect any behavior, any problem and see the thousands or millions of causes that led up to that behavior. I have one of the pages in front of me that I've copied from my skills book that has so many of my notes in it. You probably remember the page, it's what makes it hard to regulate your emotions. This is probably one of the 10, you know, this is a 350 page, 400 page workbook. There's probably 30 or 40 pages that I have stickies in and this would be one of the 10 most important. And it's just this great reminder, just for the person listening to this.

So what makes it hard to regulate your emotions? Biology. Let's just acknowledge there are biological differences between us. Our brains are different. I won't go into some of the details there, but anybody who has many kids more than one will recognize that they are simply different, even if they're raised identically. One that we already talked about, lack of skill. Lack of skill because skills were not taught, because good skills were pushed away or because bad skills were reinforced. I think this comes from it, which is

reinforcement of emotional behavior. So going back to childhood. This one's very interesting, right? Moodyness. Your mood in the moment will alter your ability to regulate emotion. This one I can relate to a ton, which is emotional overload. So the more pressure you have on you, whether self-imposed or otherwise, the more difficult it is, and then one that I love, which is emotional myths, mistaken beliefs about these things. I have my own notes here. One of them says, when I can't regulate, it is almost always the case that at least one and typically three of these are happening. So it's very interesting.

Again, three of these really peg to childhood, right? The biology, the reinforcement of emotional behavior, plus or minus skill in the emotional myths. Yes, a lot of them are longstanding patterns and some of them are current and also contextual. For example, there might be a person in your life, just one of many that actually when you display anger, gives in to everything you're asking.

This could be totally outside of your awareness, but that means that you're more likely to have that anger response with that person in that context in the future. I had a while before my husband, ex-boyfriend at one point who, when we would argue, if I started to cry, he would immediately back down. And this was outside of my awareness that this was happening, but I've realized over time I found myself crying a lot more than I ever had before. I'm not saying crying is good or bad, but I just noticed that that was what was happening because in that context with that person, that behavior was being reinforced. And I feel like this could happen so subtly and it's so contextual.

And why we're sometimes different with different people is because of that. This is often at least as it relates to BPD is pathologized. Oh, if you're different with different people, there's something wrong with you. You have no core sense of identity or something, but I would say it's actually pretty normal. We're all different with different people because the context often call for

that. And it's adaptive to be that way. So is it essential for everybody who's practicing DBT to also be practicing mindfulness meditation, given the importance of that first step, which is recognizing the thought. What we might have to disentangle what we mean by mindfulness meditation, because I would say mindfulness as a skill is central to everything. So let me rephrase the question, given the importance of mindfulness as a central tenet to this entire practice, is it also suggested that people use a form of meditation that practices that skill, typically focusing on something like the breath or an object

and bringing their attention back to that every time it wanders. We have actually debated this within DBT, and I remember, actually there was a while that Marcia was when I was a student of hers and therefore seeing her every day, she was on this kick lack of a better word saying that we need to get all the therapists to practice seated meditation like you're describing for at least 20 minutes every day. And actually there's a form of cognitive behavioral therapy called mindfulness-based stress reduction, MBSR. You may have heard of it for depression, in which they teach people who are in the treatment to work up to that seated meditation. And they also require that therapist who

do MBSR also practice it that way. And so, Marcia was thinking, do I need to require this? And I remember even way back when arguing against it at the time, because I thought that's not actually practical for everybody always. I think about working a single mom with three kids and to say, you need to find 20 minutes a day to do seated meditation is impractical. There have been many times in my life where that was impractical as well. And part of this was to try to figure out like, how do we define a DBT therapist? How do we know when somebody is doing DBT? She never ended up requiring or saying that therapists have to do this. But what she would say is that therapists who practice DBT have to have a mindfulness practice,

but that practice could be anything under the umbrella of mindfulness. So you do yoga that could be your mindfulness practice or you do mindful walking or you do mindful participating in various things. That is something when it comes to clients who are in DBT, we want them to strengthen their mindfulness muscle. Absolutely. And if I have clients who are interested in learning to do seated meditation, that's amazing. And I would support that entirely. I think for a lot of the clients that we work with at my clinic, that would be too big

a jump. And why Marcia doesn't say that clients need to do this. For a lot of people who are in DBT who might be at that more severe end of the continuum, just sitting with themself and their thoughts and their minds without doing anything to change it for a minute could be excruciating. So we're trying to build that tolerance, of course, but the mindfulness skills in DBT are much more concrete and practical and designed to be used in any moment rather than designed to facilitate a more formal practice. Obviously, we can't cover DBT in any comprehensive manner.

There's so much, but there are a couple of things I'd love to just highlight that I have found very helpful and I'd love to kind of hear you expand on them. One is opposite action for anybody who's done DBT, you'll grin or grimace depending on because how hard it can be sometimes. Do you want to explain to people what opposite action is and when we use it, what's the use case for this? Yeah, I did my dissertation on opposite action. I did. So opposite action is a skill that falls into the emotion regulation module and it's a skill for changing an emotion that you don't want to have. And it's simple in concept and hard to execute because simply put, it's engaging in the opposite

of what your urges are telling you to do. And that's why it's called opposite actions. So we know that from emotion science, from our own experiences that are experience of emotions are associated with an urge to act in particular ways. So when we feel sad, we have an urge to retreat or withdraw. When we experience anger, we have an urge to lash out when we experience shame. It's to hide fear. It's to fight or flight. fear, it's to fight or flight. And so what opposite action says is that when your emotion does not fit the facts of the situation or is too intense for the

situation and you want to change it, a way to change it is to act opposite to your urges. So what I'm sad, instead of withdrawing, I activate when I'm fearful, instead of running away, I approach kind of like the exposure we were talking about earlier. When I'm experiencing shame rather than hide, I actually confront or disclose and so on. So it is really hard to do, but you get better at it over time. I will say that if you practice, I don't know if that's been your experience. It has been, but what I want to tell you practice, I don't know if that's been your experience. It has been, but what I want to tell you, and I guess you'll appreciate this given

your background, especially, is I mentioned earlier anger being a profound emotion that I'm very familiar with. The other one is, I don't know what the underlying emotion is, I haven't really figured it out yet. I don't think it's sadness, but it produces a phenotype of needing to isolate, just a desire to completely isolate. So these are two areas where oposite action becomes very helpful. One of the really interesting things that if you told me this five years ago, I would have never believed it, but it's remarkable is the use of cold water to calm the nervous system in moments of high-fighter flight mode.

So that's part of the oposite action effect there. I feel angry. I'm going to go and do something that's really calming, which is taking ice shower or jumping the cold pool. This is nice in the winter here in Austin because we still have pools open and they're really cold in the winter. But that's harder. Those are harder to do, as you probably can imagine. When you're at nine out of 10 activation and your desire is to scream or break something to then walk yourself back from that is harder. Where I have found opposite action to be remarkably helpful and helpful to the point where it's

now the norm. This might be my biggest win so far is when all I want to do is isolate, forcing myself to go and play with my kids. And I remember the very first time this happened, it was about a year and a half ago. And for reasons I didn't understand, it was a Sunday morning, I wanted to sit in the office and do work and exercise and just do my own thing and be my own thing. And my wife said, hey, we're going to go to Barton Creek and play on the rocks and throw rocks and the water and stuff.

And that's the sort of thing I would have said, absolutely not. I'm too busy. I'm overwhelmed. I need to just do this thing. And she would have accepted it. She would have been upset. And she would have accepted it and she would have left. And I was like, okay, let's go. Now I didn't want to go at all, Shereen. I mean, the thought of not getting my work done and missing a workout potentially and then going to some place where it's totally unstructured and there's going to be other kids potentially and it's going to be loud like everything about that was unappealing and we had this amazing time doing nothing literally playing games like who could get across the creek without getting

the most water in their shoes exactly what you'd expect and then And then on the way home, we stopped and got a burger and fries like the last thing I'd wanna do, right? Like we did everything I would never wanna do. And I got home, I felt great. And I didn't get as much work done. You do that enough times that you realize this really works. This is the key for me, this is important.

When I don't wanna engage with anybody, go and engage with my family because that's the drug to get out of this. Yeah, I think opposite action is really a remarkable tool. Think of a simpler one, smiling when you're furious. And meaning it, what Berkshire talks about is this opposite action all the way because we all know what a fake smile is and a fake smile while you're also in your mind thinking, oh, what an asshole. I hate this person. You know, like that's not opposite action because that's what we might say, half-assed opposite action. It's not going to work because your mind is still going to be angry, but what's going to happen, really, what we're talking about with opposite action is if we act opposite to our urges, we're sending the feedback back to our brain to feel a different way. I think a lot of people relate to the idea of doing opposite action, like what you said, but also work because you're anxious and maybe you have a long history

of avoiding saying anything or doing anything because you're anxious. So opposite action would be to say throw yourself into that, go to that party even though you don't want to and then throw yourself into the party, which is what you described with your family. Like you could have gone along physically, but all the while I've been thinking, oh, I need to be back home. Yeah, I could have been sitting there on my phone or goofing off. Yeah, or thinking this is stupid or whatever,

but you threw yourself into it when you were there. And I think that that's the critical piece. It's not just the moving your body there. It's throwing your mind into it as well. What else do you think could be really interesting for a person who's never heard of DBT to understand as they themselves contemplate, Hey, is this something, is this a new skill I should learn? It's no different than saying, I'd like to learn tennis because I know that as I age,

full court basketball might be hard for me, but tennis is something that I'll be able to play for longer. Therefore, I want to go and learn this skill. I'm going to need to coach, I'm going to need to practice, and a year from now, I'll be better than I am today. Do you think that's a good way to think about DBT? Well, I do with some caveats. Anybody who reads any news or is living their lives right now knows that what we're hearing about is the idea that we're in mental health crisis or that there's endless mental

health crises right now. And what we know is that there are just simply not enough mental health providers to treat all the need that's out there. And what that has meant on a practical level is that there are huge long waiting lists for treatment everywhere for most people. We don't want that to deter people from seeking out help when they need it. But the point I want to make as it relates to that is that I don't think everybody needs full on DBT. And we don't yet have the science really. This is actually an area of research that I'm interested in is trying to figure out who does need the full package of DBT versus who can benefit from a lighter touch,

a lower dose, you know, whatever word you wanna use there. Because we wanna be efficient in our mental health delivery. We also want people to learn to reduce suffering of people on a mass level. Is DBT something this sort of interrupt? This will fit into what you're saying. Is DBT something that can be done somewhat effectively on your own, meaning with manuals, with books, with videos online versus the way you would work with people who are much sicker where you have to be working with them directly in person.

So this is what we don't know yet. I think we have some assumptions about this, but I don't even know if our assumptions are that valid, but I think the assumption was always, for example, that if somebody is experiencing suicidal thoughts, they absolutely need some form of treatment and it needs to be in person and it needs to be x, y, and z. And I think COVID actually threw us into this new world that we weren't expecting, because we had to start treating people who were suicidal virtually, for example. And we were able to realize that this idea that we had to see people in person was a myth

that we believe. And there were reasons why we believed it, but there doesn't seem to be any as far as we know so far, any added risk of seeing somebody through telehealth when they're suicidal. So I think a lot of our assumptions about what people need are assumptions that we don't actually know a lot about an area of research that I'm interested in and that I actually applied for some funding to do is to do kind of a stepped care model of DBT

to start everybody with what we might call a low dose intervention, like videos of skills, and see what percentage of people benefit from that, and from that alone, versus what percentage of people don't benefit enough, need something else. And then what can we add to that? That would be a slightly step up, like maybe some phone coaching, you get a call with somebody once a week about how to apply the skills in your daily life, then test it again, right?

And then if you're not responding to that, maybe then you get offered the full package of DBT or something else. And we basically can identify through that kind of study, what are the sequences of care that are going to be most effective that will help the most people and can be disseminable. So that's an area of research that I would love to do. We don't have a lot of knowledge about that.

But I'll say, and I think we spoke about this very early on, is that I honestly believe that anybody could benefit from learning DBT skills. And so to that end, I would say yes. I think there is a value to your listeners to say, expose yourself to some of these skills. See, if, and there are videos, there are books, there are things that you could do to learn more about them. See, if you resonate with them, see if you can apply them on your own, and you could do to learn more about them. See if you resonate with them, see if you can apply them on your own. And if you want to know more or you're struggling to apply it in your life, then that might be where you could reach out for

help and find a DBT therapist. Now, speaking of that step, Shereen, how does a person know when they find a DBT therapist? How can they verify that they're well-trained? You're probably an exception in that you trained directly with Marsha. There are obviously a number of people who train directly with her, but that's not scalable. So at some point, you're going to meet a potentially wonderful therapist who doesn't have that lineage.

So how is the field of DBT self-regulated or self-policed? So it's been a long-standing process to try to figure this out. You know, mental health is really screwing in this way because there are so many ways in which a person can become a therapist, hang a shingle as either window and practice therapy, and that person can call themselves a DBT therapist, or a CBT therapist, or any kind of therapist, and may not have the credentials or training to back that up. I always tell people to proceed with caution and to do your research when you're looking into finding a mental health provider. Marsha was against this for a long time.

She was against this idea of certifying DBT therapists. She didn't want to have regulatory role. She wanted people to learn DBT and to just sort of get DBT out there. But then she was hearing more and more stories as we all have now with people saying that they received DBT and it didn't work. And then you ask them what happened in their treatment and you hear details about their treatment that were clearly not DBT. And the worst case scenario is somebody dies by suicide or has a terrible outcome thinking that they're getting DBT when they're not.

So a few years ago, she started the Linehan Board of Certification LBC, which has started a certification process for DBT therapists. So what I will say, all people that are certified by LBC to be DBT clinicians are likely good clinicians, good DBT clinicians, because they've met all of these standards. But not all people who are not certified are bad DBT therapists, right? Because there's a number of DBT therapists who have just elected not to go through the process of certification. If you're first starting to think seriously about DBT, you might start by looking up certified DBT therapist

but recognizing that that's not the only criteria to use. Are there any other questions that a person can ask to determine if the pedigree of the person who's going to be conducting their therapy is truly in line with the principles of DBT as opposed to something that's been bastardized and sort of misused. So I'll share another Marsha anecdote in response to that question because relatively early on, sort of after the initial trials of DBT were put out showing that DBT was effective. Insurance companies started getting interested and wanted to pay for DBT, but didn't want to pay for non-DBT.

And so they would call Marsha up and they would say, this person says they're doing DBT, how do we know if they're really doing DBT so that we can reimburse for the service. And she thought about it and ultimately said, ask the DBT provider if they're on a consultation team. Now I think that this is oversimplified by far, but I'll explain that one of the aspects of DBT

or one of the components of the full package of DBT in addition to individual therapy and skills training is that the DBT therapist, him or herself, attends a weekly consultation team meeting with other DBT therapists. And the consultation team meeting is a place where DBT therapists talk about their experiences delivering DBT with an aim towards improving their own adherence to the model and their motivation. It's often called therapy for the therapist.

And I think Marta's response to that question was important because in many places, somebody might say, I want to learn DBT and I can provide her might say, oh, I've learned the DBT skills and I can teach my clients DBT skills. And I'll just pick and choose what I want to do out of DBT. And the first thing they elect to drop is the consultation team meeting because it's time, right?

It's time and effort and it's centered on you improving yourself as a therapist. I think it holds up though as a reasonable question to know to what extent is the person that you're looking into adhering to DBT principles is to ask whether they're part of a DBT consultation team. That's a great litmus test actually. I really like that. I don't know how many people it'd be interesting to know. Shureen, this was fantastic. I know we're going to get to meet in person in about six weeks, so I'm really looking forward to that. Thank you so much for your time. This is a hard topic. It's so big and it's so big to get your arms around it all. And I want people to come away from this,

not at all thinking that they know what DBT is, necessarily from this, but I hope we've peaked someone's curiosity such that they go out, they watch some videos, they maybe pick up a book or a skills book and decide, hey, is there something in here for me? And maybe for some, it means going as far as someone like me has gone and and saying

I'm gonna make this a regular part of my training. It was really fun talking to you So thank you. Thanks, Trayne. Thank you for listening to this week's episode of the drive. If you're interested in diving deeper into any topics We discuss we've created a membership program that allows us to bring you more in-depth exclusive content without relying on paid ads It's our goal to ensure members get back much more than the price of the subscription. Now, for that end, membership benefits include a bunch of things. 1. Totally kick ass comprehensive podcast show notes, the detail every topic paper person thing

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