Episode Overview

Podcast: Mental Illness Happy Hour
Host: Paul Gilmartin
Episode: #740 - Dialectical Behavior Therapy - Dr. Blaise Aguirre
Date: March 21, 2025
Guest: Dr. Blaise Aguirre
Main Theme:
This episode centers on borderline personality disorder (BPD), dialectical behavior therapy (DBT), and the pervasive issue of self-hatred. Dr. Aguirre, a leading psychiatrist specializing in BPD and DBT, discusses misconceptions, treatment strategies, personal narratives from listeners, and the nuanced realities of living with and treating BPD. The latter half delves deep into the origins and unlearning of self-hatred.

Key Discussion Points and Insights

1. Introduction & Listener Connections

• Listener Surveys: Paul reads a range of anonymous listener submissions, illustrating real struggles with relationships, fear, attachment, and emotional pain.
• Main takeaway: “Walking through that fear is... about more than just that instance or that relationship... we get to develop a self-care muscle that is then stronger for us to utilize in future situations.” (Paul, 05:00)

2. Borderline Personality Disorder—Characteristics and Myths (18:13–29:40)

Core Features of BPD

• Emotional Dysregulation: Persistent difficulty managing emotions, reacting intensely to triggers most would find minor.
• Fear of Abandonment: “They fear that [abandonment] is going to happen... and then because they’re so terrified, they start to behave in ways that can sometimes be somewhat off putting to the other person.” (Dr. Aguirre, 19:38)
• Intense Relationships: Relationships swing between idealization and devaluation; rapid shifts in how others are perceived.
• Sense of Self: Unstable self-image, chronic feelings of emptiness.
• Suicidality: High rates—up to 10% of hospitalized individuals ultimately die by suicide.
• Pain as Survival: “The emotional pain that people with borderline personality disorder feel is so intense that the thought of suicide comes to their mind as a way of ending emotional pain.” (Dr. Aguirre, 22:24)

Common Myths and Stigma

• Manipulation & Attention Seeking: Misunderstood as intentional, when behaviors are actually desperate survival attempts.

  “If they’re manipulative, they’re very bad manipulators because they’re not ending up getting what they want… Burning a bridge, getting psychiatric treatment.” (Dr. Aguirre, 23:16)

• Prognosis: Myth that people with BPD can’t get better; evidence-based therapies like DBT refute this.
• Relationship Potential: “...when they've learned how to regulate and how to manage relationships and how to manage strong emotions, they're just ordinary people with very strong emotional system.” (Dr. Aguirre, 29:44)

3. Dialectical Behavior Therapy (DBT) for BPD (29:40–52:38)

What is DBT?

• Origins & Philosophy: Developed by Marsha Linehan—DBT bridges cognitive-behavioral intervention with radical acceptance and mindfulness.
• Balance of Validation and Change: “You can only get to change through accepting who they are in the present moment.” (Dr. Aguirre, 39:00)
• Evidence Base: The only therapy for BPD with extensive research backing; “No other psychotherapy up until then, and actually I would say up until now, has stood the test of so much rigor.” (Dr. Aguirre, 40:42)

How DBT Works

• Triage Approach: Prioritize urgent behaviors (suicidality, self-injury) before addressing deeper issues.

  “If I don’t target the suicidality, then all the rest of the stuff isn’t going to matter. I can’t deal with childhood trauma... if you’re dead.” (Dr. Aguirre, 30:34)

• Skill Building: Focus on teaching emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness.
• Validation of Coping Methods: Even maladaptive behaviors like self-harm serve a purpose—short-term relief at a long-term cost.

  “Can a problem and a solution, can the same thing be a problem and the solution at the same time?... For people with BPD, self-injury actually is calming for the brain.” (Dr. Aguirre, 43:34)

• Function Over Form: It’s about why people do things, not just what they do. Even ‘positive’ behaviors (like excessive homework) can be avoidance tools.

On Humor in Recovery

• Humor and irreverence can help break through the darkness and build therapeutic connection.

4. Unlearning Self-Hatred (52:22–87:15)

Self-Hatred as a Widespread, Neglected Issue

• No Books on Self-Hatred: Dr. Aguirre notes, to his surprise, there is almost no literature or books specifically on self-hatred—even though it's a core driver in many forms of suffering.

  “If you look up DBT books, there's thousands...If you look at mindfulness books, there's thousands...If you look up self-hatred, nothing.” (Dr. Aguirre, 61:18)

Origins and Maintenance

• Self-hatred is learned: “A child is not born hating itself...if you learn how to hate yourself, you can learn how to not hate yourself.” (Dr. Aguirre, 69:17)
• Teachers of self-hatred: Abusive/invalidating parents, bullying, trauma, and a lack of validation or protection. Also, absence or trivializing of emotional sensitivity.
• Emotionally Sensitive Children: More prone to absorbing negative labels and internalizing them.

How to Undo Self-Hatred

• Identifying Teachers: “…Who were your teachers? Tell me who your teachers were. Was it the bullies? Was it a parent who didn’t protect you…?” (Dr. Aguirre, 72:34)
• Challenging Toxic Messages: Break down the negative internal messages and see if they carry any valid weight.
• Live an Antidepressant Life: Instead of just relying on medication, encourage activities and connections that create positive feelings and meaning.

  “If I know that not calling my friends, staying in bed, not eating, not showering, perpetuate depression, calling my friends, going for a walk, having a healthy meal, shaving and showering makes me feel better...” (Dr. Aguirre, 81:16)

• Esteemable Acts: “If you want to improve your self-esteem, do esteemable acts.” (Paul, 82:33)

Contextualizing Shame & Self-Acceptance

• Moving from judgment to curiosity and compassion; reframing behaviors as attempts to self-soothe rather than moral failures.

5. Notable Quotes & Memorable Moments

• On Emotional Pain:

  “If your house...were to catch fire...imagine the emotional brain on fire, it's very, very hard to think for any of us, independent of whether we have borderline personality disorder or not.” (Dr. Aguirre, 24:39)

• On learned self-hatred:

  “You weren't born fundamentally bad. No matter what you think, that is the greatest fake news that there is.” (Dr. Aguirre, 86:10)

• On the function of maladaptive behaviors:

  "Even though those were very powerful tools for you...there's no judgment about it. It's just the thing that people do to feel better." (Dr. Aguirre, 47:07)

• Connection vs Comparison:

  "People in connection with somebody that matters hate themselves less. But rather than connect, we compare, and contemporary industry markets to self-hatred." (Dr. Aguirre, 84:44)

Timestamps for Important Segments

| Timestamp | Segment | |--------------|-----------------------------------------------------| | 00:00–17:14 | Listener Surveys, Fear, and Self-Exploration | | 18:13–29:40 | Introduction to BPD & Myths | | 29:40–52:38 | DBT Explained: History, Mechanisms, and Use Cases | | 52:38–60:53 | Self-Hatred – Literature Gap & Emergence | | 60:53–69:13 | Origins and Deep Nature of Self-Hatred | | 69:13–87:15 | Unlearning Self-Hatred and Practical Interventions | | 87:15+ | Closing, Listener Stories, Reflections |

Additional Insights

Humor and Humanity

• The episode is shot through with dark humor and gentle irreverence, serving both as a balm and as a reality check for those in deep emotional distress.

Practical Takeaways

• You can learn to undo toxic self-beliefs.
• Effective therapy involves triage and prioritizing survival.
• Behaviors—even ones we dislike—always have a function; challenge the shame, not the behavior.
• Recovery is a communal and deeply personal journey.

Resources Mentioned

• Dr. Blaise Aguirre’s book: I Hate Myself: Overcome Self-Loathing and Realize Why You’re Wrong About You (with forward by Jewel).
• DBT centers (reference to the Harvard-based DBT program).
• Jewel’s Inspiring Children Foundation (mindfulness and resilience training).

Overall Tone

Empathetic, candid, and often wryly humorous. Both Paul and Dr. Aguirre maintain a compassionate stance toward suffering—never minimizing pain but also refusing to stigmatize the messy reality of mental illness.

For Listeners Seeking Support

• DBT is an effective, research-backed intervention for BPD and other emotional regulation struggles.
• Self-hatred is not a permanent truth—it is a learned belief that can be unlearned.
• Connection (not comparison) is antidotal to shame and self-loathing.
• Community, professional support, and cultivating new coping skills are key to moving forward.

Summary prepared for those who want a complete grasp of episode #740, independent of direct listening.