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The Carlat Psychiatry Podcast
BPD Series, Episode 3: Dialectical Behavior Therapy — Balancing Acceptance and Change
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- [00:01]
A
Hi everyone and welcome back to the Carlette Psychotherapy Podcast where we review different psychotherapeutic approaches for you to better expose you to the wide range of evidence based modalities available. I'm your host, Abigail Rossell and today we will be continuing with episode three of our Borderline Personality Disorder series, diving into dialectical behavioral therapy, DBT, with the one and only Dr. Sherene Risby. Doctor Sherene Rizvi is a licensed clinical psychologist who's board certified in both dialectical behavioral therapy and cognitive behavioral therapy. She received her PhD from the University of Washington where she trained directly under Marsha Linehan, who is the developer of DBT herself, and for the past 25 years has been deeply involved in the research, clinical practice and dissemination and training of dbt. She's published and presented widely on the subject and also leads clinical training and clinical services in dbt, serving as Director of Psychology Training and Director of DBT Services and Research at Montevier Einstein in New York City. So thank you so much, Dr. Risby, for joining us today.
- [01:18]
B
Thank you so much for having me.
- [01:20]
A
So to start off, I'd like to give listeners just a broad orientation to dialectical behavioral therapy as a treatment for bpd. If you could start off by speaking, speaking about this word, dialectics, what that means and how that sort of frames the treatment in general.
- [01:36]
B
So dbt, as you're well aware, is dialectical. And I certainly relate to this idea that most people don't understand what that piece means. And actually, even when Linehan first published her treatment manual, the treatment manual is called Cognitive Behavioral Therapy for Borderline Personality Disorder, because at the time her publisher said, we can't put dialectics in the title. No one will know what that is. No one will buy it. So that's why the manual is called Cognitive Behavioral Therapy, and also because the treatment is cognitive behavioral therapy. And so that's something that's important to recognize that it is a form of cbt and it adds some elements to cbt, and in particular, the element it adds is this notion of dialectics, which is this idea or this philosophy that everything in the world is interrelated, tension is inevitable, polarization is inevitable, and that in order to be effective in our lives, we have to learn how to navigate that tension. And usually what that means is looking for the truth in both sides of the polarization and searching for a synthesis. So in dbt, the primary dialectic that we talk about is the dialectic between acceptance and change, where acceptance is accepting your life, the world, your Problems, your relationships exactly as they are. And change is realizing I don't like all of these things about my life, and I want them to be different. And so we're constantly striving to find the synthesis between those two, what is important to accept, and what can we change and what can we actively do to work towards your life being different in a way that is reasonable and gets you closer to your goals?
- [03:23]
A
That's really interesting. And one of the things that I was thinking about as you were sharing, that is I could certainly benefit from that perspective in my own life. I think a lot of us could benefit from having that perspective. So I'm curious what it is about the nature of how you understand Borderline Personality disorder that makes this focus on the dialectics so crucial in its treatment.
- [03:44]
B
A couple of points about that. From a behavioral point of view, which DBT is, we think about borderline Personality disorder as a continuum. And people with borderline Personality disorder are very similar to us in many ways, except for the problems that they experience. Perhaps the behaviors they experience are more severe, more intense. But if we look at it from that point of view, then I completely agree with you that we all benefit from dialectical thinking. We all benefit from learning about how to navigate the tension between acceptance and change. We all benefit from recognizing that tension and polarity is inevitable. So I think that's really a critical point here. And I think why so many clinicians are attracted to DBT as a therapy is that they realize that it is helpful for them in their own lives.
- [04:29]
A
So as we're starting to talk about the problems that individuals with BPD experience, I'd like to take a step back for a moment and talk a little bit about how practitioners within the DBT school of thought really conceptualize the BPD in general. So I know that a lot of people from the DBT school understand BPD as emerging from the biopsychosocial or the biosocial theory. Could you speak a little bit to that? What is it and how does it frame how we understand what BPD is and where it comes from?
- [04:57]
B
Yeah, so the biosocial theory was developed by Linehan as she was developing this treatment as a model for understanding how is it that some people go on to develop bpd. And the first piece of the biosocial model is the presumption that the core of Borderline Personality Disorder from this framework is pervasive emotion dysregulation. So when we're talking about the biosocial model, we're actually saying not necessarily How BPD develops, but how does pervasive emotion dysregulation develop? And so the biosocial model posits that pervasive emotion dysregulation develops as a result of a transaction between two things, biology and a social environment. Specifically, it's referred to as the invalidating environment. So the biology piece is a presumption again that there are some people that are born or very early in childhood develop a sensitivity to experiencing emotions more intensely, more reactively, and with a slower return to baseline. And we presume that there is a biological aspect to this, and that could be genetic, that could be biology, factors that develop in utero, in early childhood, as your brain is developing, etc. But there's assumption that there's something biological about this. On the other side is what's referred to as an invalidating environment, in which the person's experiences and especially their emotional experiences are pervasively, chronically, invalidated, negated, dismissed, et cetera. The key piece of the biosocial model, which also speaks to the dialectical nature of things being interrelated, is that actually we say that the biological side and the invalidating environment side transact with each other. And what we mean by that is that each side affects the other. So that if you are somebody who is born more sensitive to emotional experiencing, you are likely exerting pressure on your environment from a very early age. And that pressure on your environment from an early age is actually more likely than to elicit invalidation. Then the more invalidation you receive, the more sensitive you are, the more your reactions become more intense and stronger. And again, that exerts more pressure on the environment, which creates more likelihood of invalidation. And that transaction goes back and forth and heightens both sides to the point where a person develops more pervasive emotion dysregulation. They learn that the only way to get attention or to get what they want is to have a very extreme reaction. They learn to self invalidate because they're so used to receiving invalidation from the environment, they learn to shut down so that they're not invalidated. So all of these patterns of behavior that go on to develop into borderline personality disorder symptoms are a result of that transaction over time.
- [07:57]
A
So to your earlier point about understanding borderline personality disorder as really being an emotional dysregulation disorder, would you say that is the core dysfunction that DBT is trying to target is the emotional dysregulation that arises from bpd?
- [08:13]
B
Yes. And this is something that sets it apart from the Other theoretical models and treatments is that is the premise of DBT is that emotion dysregulation is the core of the disorder. And all of the other symptoms, characteristics, problems associated with borderline personality disorder are a result of emotion dysregulation.
- [08:36]
A
So following that path, I'd like to really dive into the treatment and understand what it looks like and how it functions more in practice. So you mentioned at the very beginning that the treatment is really built upon two things, which is acceptance and change. Obviously seemingly very paradoxical. So I would love to hear how you address both of those simultaneously in practice and what that really looks like in the treatment.
- [09:00]
B
As a clinician who is delivering dbt, we are holding a lot of things in our mind at the same time. We are striving always to see multiple perspectives. We want to understand how is it that a person is behaving the way that they're behaving and feeling the way that they're feeling. And we are implementing the acceptance side of the dialectic by doing a lot of validation. Validation is a key strategy in dbt, and it's the strategy that is meant to embody that acceptance side, that it makes sense that you feel the way you feel. It makes sense that you self harm, because self harm is the only thing that helps you feel better in the moment. Until now. It makes sense that you are shut down in your session with me because in the past, whenever you've expressed emotion, you've been punished. So we do a lot of validation to accept the person and to communicate acceptance of the person exactly as they are in this moment. And we always have that. And because it makes sense that you self harm, because self harm works for you. And this is not an effective strategy in the long run. Right. And it has lots of negative consequences. So we have to learn how to do something different. We have to stop self harm and we have to do something different. That's the change piece. Right? It makes sense that you're shut down in session because other people have punished you for emotion expression. That's the acceptance. And this isn't working for us in our session. I can't help you if you're shut down. So we have to get you to learn how to express yourself. That's the change piece. And so as a DBT therapist, you're navigating those two. And you're also looking for dialectical. What's the synthesis here? And sometimes it's just acknowledging both sides. Right? Self harm works for you. And we need to get it to stop that is a dialectical statement in and of itself. But sometimes it requires other kinds of strategies to move towards figuring out what can we do differently here.
- [10:57]
A
What do some of those strategies look like? Right. So you mentioned back in the beginning of our conversation that there's a manual, which is another thing that differentiates the treatment from a lot of the others that we've covered is, well, there are manuals for all of them. But from my understanding, the DBT manual really takes the clinician step by step through how the treatment is executed in the room. So if you were to give us a brief overview, obviously that's quite the undertaking of this manual and what it contains and how it provides the roadmap to this treatment. What would you say are the main parts that it's divided into?
- [11:31]
B
Yeah, so the Manual is the 1993 book by Linehan, Cognitive Behavioral Treatment of Borderline Personality Disorder. It is, you're right, a manual in that it talks about therapist through how to deliver the treatment. And I will say it is hundreds of pages long, it is very small print, it is very dense, and it can be really hard for people who want to learn to learn it that way because so much is in there. At the same time, I have to say I still look back to that book and still think it is practically perfect in the sense that it really does include everything. We say that DBT has four modes of treatment, meaning there are four components of the treatment that when you're doing DBT by the book, you are delivering these four modes. The modes are individual therapy, weekly one on one therapy, but it's done in a very particular way, which I'm sure we'll get into. The second mode is skills training. Skills training is usually done in a group format, but it does not have to be a group format, but it is weekly skills training sessions that function very much like a class and to teach people skills and enhance their use of skills. The third component is what was originally referred to as phone coaching. We can call it between session coaching. Basically, that mode is to provide help and assistance in use of skills to our patients in moments when they most need it, which are almost always outside the context of an individual therapy session. So that's what the coaching is. The idea is that somebody who's in DBT can call their therapist when they're experiencing urges to do something before they do something and get help in using skills instead, and therefore not engage in the problem behavior. And then the fourth mode of the treatment is the therapist consultation team, and this is a weekly meeting between with all the therapists who are delivering dbt. And the goal of the DBT consultation team is to enhance our skill in delivering dbt. It's really about I'm having trouble delivering DBT or I don't know what to do in this situation. And the therapists help each other become more adherent to the DBT model.
- [14:14]
A
So it sounds like it's pretty well structured in terms of having these four different categories that the treatment falls into and pretty strategically taking both the patient and the therapist through all of those to develop a comprehensive treatment program. I want to dive into the specifics of each of those. So you mentioned the individual therapy is very specific to the DBT model. So I think let's start there. What about the individual therapy makes it so unique? What are the defining characteristics that characterize a DBT session and what does that session really look like in the room?
- [14:51]
B
In individual therapy sessions, some of our principles are we have a target hierarchy that informs how we spend our session time. The target hierarchy is kind of like the roadmap for individual therapy sessions. And this is one of the rules of dbt, if you will, that if you're doing dbt, you have to attend to the target hierarchy in your individual therapy sessions. The target hierarchy is first and foremost you have to address what is referred to as life threatening behaviors. In this category we include suicidal behavior, that includes suicide attempts, that includes ambivalent suicide attempts, I overdosed on these pills, I wasn't sure if I wanted to die or not, suicide planning. It also includes non suicidal self injury, cutting, burning, head banging, etc. And we also include homicidal urges or actions. And if there is any life threatening behavior present currently or in the past week that receives the highest priority in our session, the mantra is first save life. That's what we're doing in our hierarchy. The second target in our hierarchy is what's referred to as therapy interfering behaviors. And therapy interfering behaviors are any behaviors on the part of the patient or the therapist that interferes with the delivery of the treatment. So somebody coming late, somebody being intoxicated, somebody not going to skills group, a therapist being late, a therapist not paying attention. These are all what we refer to as therapy interfering behaviors. And if these are present, then we want to address them. And if there's, let's say no life threatening behaviors in the past week, but there are therapy interfering behaviors, then the therapy interfering behaviors receive the most time and attention. Then the third in the target hierarchy is what's referred to as quality of life interfering Behaviors. And in a way, that's what we would say is everything else. But it's all the behaviors that interfere with a successful, meaningful quality of life. Substance use, impulsive behavior, poor interpersonal relationships, trouble holding a job. What is interesting and what your listeners might identify already is that people usually come into treatment for those quality of life interfering behaviors. And this is sometimes then a point of tension because somebody comes in and they harmed themselves in the past week. This happens to me all the time. I harmed myself last week, but it's done, it's over. I don't want to talk about it anymore. I want to talk about this problem I'm having with my friend. Right. The DBT therapist has to attend to the target hierarchy, which suggests that the self harm behavior is at the top of my hierarchy list for that session. There might be therapy interfering behavior in the sense of the person saying, I don't want to talk about this. That also has to be attended to in some way. And the problem with the friend is probably considered quality of life interfering behavior, which means it is not as important from the therapist point of view to get to in that session unless you've already attended to the self harm and the therapy interfering behavior. So the person comes in and says, I want to talk about this fight with my friend. And the therapist says, I want to talk to you about your problems with your friends. That is really important to me too. The only way we're going to have sufficient time to talk about the problems with your friends is if you don't harm yourself and you are engaged with treatment. We're setting up contingencies too. To say this has to not be an issue anymore. This life threatening behavior has to not be an issue anymore. In order to get to the quality of life behaviors,
- [19:17]
A
I'd like to naturally go in the direction that you left us in, which is these skills. From my understanding that skill building is one of the defining characteristics of dbt. And I'm curious, what skills in particular are you working on building in DBT and how do you do that in practice?
- [19:37]
B
Yeah. So this notion of skills training and teaching people skills and actually stems also from the biosocial model that we already discussed, which is to say that as a result of that transaction between biology and invalidation, the presumption is that people never learned effective, skillful ways of managing their emotions, of being interpersonally effective. Because if you've been invalidated, you don't learn how to be effective with other people. You don't learn how to tolerate and manage Distress effectively and you don't learn how to accept things as they are. So those are the deficits. So we say that DBT has a skills deficit model, which is to say that what people need to do in order to improve is to learn skills that they either never learned or before, or maybe learned, but hasn't been strengthened or reinforced in their lives. And in skills training, there's a curriculum. It's like teaching a class. Here are the lessons, here's what you want to cover in each lesson. And if you're doing kind of standard DBT for adult populations, it takes about six months of weekly skills training to go through all the basic skills as intended. And so what we're teaching in those six months of weekly sessions are four categories of skills. We're teaching mindfulness skills, which we consider actually be core to all the other skills, learning how to be aware and awake to the present moment. We have very specific, concrete skills to teach people. Mindfulness. Second category is emotion regulation skills, where we teach people how to learn to identify emotions that they're experiencing, how to identify the different components of an emotion, how to intervene at different places in an emotional experience, to get things to go a different way, to reduce the intensity of an emotion or to change the emotion, and how to reduce our vulnerability to emotions. We also teach people distress tolerance skills. That's the third category. And in that we're teaching people how do you tolerate certain stress, distress crises in your life without doing anything to make the situation worse and to recognize that we can't avoid all stress and distress. So when it comes up, how do we cope with it effectively? And then the fourth category of skills are the interpersonal effectiveness skills where we teach people how to be more effective in, in talking with other people, in getting what you want in interpersonal situations, in enhancing your relationships with other people, and in enhancing your self respect in interpersonal situations. We cover all that in interpersonal effectiveness. So that's happening in the weekly skills training groups. The individual therapist is aware of what the person is learning in the group and is looking for opportunities based on what's happening in the individual session to say, okay, let's pause there. Instead of reaching for that razor blade or instead of reaching for the alcohol, what could you have done differently? What skill could you use? And then what got in the way of you using a skill? We're thinking about replacing those ineffective behaviors with skillful behaviors.
- [23:26]
A
If I'm understanding correctly, it sounds like a standard or comprehensive DBT program always has group sessions as part of it. And that's really where the client is learning the skills.
- [23:37]
B
I will say most of the time it involves group skills training, but it was never meant to be mandatory that it has to be in a group. It could be individual skills training sessions. But yes, to your point, they are learning skills at the same time that they're also engaged in individual therapy.
- [23:54]
A
So that's another feature that differentiates it from some of the other treatments that we've covered. How do you understand the role or the importance of that group therapy session in. In working with BPD clients? You've mentioned that interpersonal piece. Do you feel that interpersonal dysfunction or effectiveness is also worked on in a more indirect way by doing a lot of this work in group therapy sessions?
- [24:16]
B
I do think there is experience of validation that happens in the context of group to recognize that I'm not alone in this, that other people are struggling with the same problems that I'm struggling with. I think that there's also this piece of learning from each other. So when I run a group and I we just did a group of teaching people Dear man, which is the interpersonal effectiveness skill of asking for something that you want. And everybody shares their Dear Man. And then other people can chime in and say, what if you did this instead? Or what if you tweaked it this way? And so there's kind of becomes this idea that we're all invested in each other learning the skill. That can be really nice too.
- [25:01]
A
I'd like to go into that. Dear Man. That phrase probably does not make a lot of sense to our listeners. From my understanding, a lot of DBT skills are structured around acronyms. And it sounds like Dear man is one of those acronyms.
- [25:16]
B
DBT has a ton of acronyms that can be off putting for some people. And we have to remember that acronyms are really just mnemonic devices. They're designed to help us remember things. That's all they are, so we don't have to attach too strongly to them. We talk about Dear man because it's a lot easier to say Dear man than it is to say the seven steps of what Dear man is. And it helps us remember, especially in the heat of the moment. Okay, what do I have to remember here? Dear Man. Let me walk through those steps. The Dear man skill is the skill to teach people how to ask for something in a way that increases the likelihood that another person will give it to you, or how to say no to something in a way that the other person will accept. So we all have situations in our lives like this, you know, we could say, how do you ask your neighbor to turn down the noise? How do you ask a friend to go out with you when they haven't been attending to you very much? There's loads of situations in which we could think about this. And sometimes for people that are really have a lot of deficits in this area, really don't interact very effectively with other people, it could be, how do you ask for a coffee drink? With a couple of modifications in a way that's effective. We could use anything as a way to practice the deer man. So the skill stands for the seven steps are describe, express, assert, reinforce. That's the dear. And that's pretty much what you say when you're about to ask for something or say no to something. And the man piece is usually how you say it. So M is being mindful, staying mindful and on track with what you are asking for. A is appearing confident, basically acting as though you deserve to get what it is you're asking for. And N is negotiate, which is if you're not getting what you want to keep at it and to negotiate for something that might be close to what you want. So the dear part, let's take an example. Something that came up in my group actually just last night was a client who lives with her mom and her dog. And her mom lets her dog go through the trash and take things out of the trash and it creates a mess and is also teaching the dog bad habits, according to the patient. And she wanted to talk to her mom about this, but she's also mindful of the fact that her mom does so much for her. Her mom is tired, her mom is doing a lot. So she doesn't want to go into it and just say, mom, stop letting the dog play with the garbage. Right? She wants to be effective, but she wants to be effective in a skillful way. So the describe is the dog has been going in the garbage and playing every night and it then leads to garbage all over the floor. Just the facts, right? No add ons, no interpretations, no judgments, just the facts. E for express is how do you feel about this? So I feel afraid that we're teaching the dog how to behave poorly. And I don't like that it creates so much mess that we have to clean up. Just express, right? Again, not adding on judgments, not adding on. You should. It's just saying this is how I feel and think about it. The A is assert. And this is what often really is hard for people is where you directly Ask for what you want. So much of the time we want to just describe the problem and want the other person to read our minds. Right. It's uncomfortable for us to directly assert what it is we want. And this is what is so important to learn. So the assert in this case would be, can you not let him go through the garbage at night? Or can we put the garbage away at night so he doesn't go in it? You're really clearly asking for what you want. The R is reinforce, which is a way of saying, how do you reward the other person in some ways ahead of time for doing the thing that you're asking them to do? So this person came up with such a great reinforce because she said something like, if we do this, there will be less mess in the house, which will be better for all of us, and I'll be less cranky and easier to live with. So the reinforce, it's really about what's meaningful to the other person. And as her mom, you can certainly understand that, yes, the mess is probably important, but also having a child who's not cranky and irritable all the time is a big reinforcer. So that would be the deer. And then the man is appearing confident. When you do it, it's being mindful, meaning if the mom says, well, you never do anything else around here. Why should I do this? The mindful piece is to stay focused on your goal. Like, yes, I hear what you're saying about those other things, and can you put the garbage away at the end of the day?
- [30:33]
A
Sounds like it gives patients, but really people in general, a very structured guideline for how to handle what could be very overwhelming and otherwise emotionally charged situations.
- [30:47]
B
Exactly. We tell people, especially when you're first learning it, it does feel very script like. As you practice it, it gets more fluid and you don't have to necessarily think about it as in this lockstep way, but when we first teach it, we say, do it in this lockstep way. See how it works, Write out the script ahead of time, practice it so that when you go into this situation that feels highly charged, stressful, or when the outcome is really important, you want to be prepared for that.
- [31:20]
A
So in terms of Dear man being a skill to help people communicate with somebody to get something they want, it sounds like that's the primary function of this skill. What would you say are a few other situations or skills that the interpersonal module addresses in communicating with people?
- [31:38]
B
Yeah, so the Dear man is pretty much the heart of the interpersonal effectiveness module. But we also have skills, skills that help you when you're delivering the Dear man. Also focus on the relationship. So like learning how to incorporate validation of the other person. I know this is a lot to ask or I know you have so much on your plate. There's so much going on and can you still do X, Y and Z? Right. And then also we focused on how do you learn to also preserve or enhance your self respect. So so much of the time we have learned over time to sacrifice our self respect in order to keep the relationship or in order to get what we want. And we teach skills for how do you actually learn to get your objective while also enhancing the relationship and enhancing your self respect and pulling that all together in as many situations as possible.
- [32:34]
A
And it sounds like that also sort of mirrors what is happening in the DBT treatment itself in terms of the therapist working to build up the client's self respect, focusing on validation, focusing on that dialectic, and then that's mirrored in what we are trying to teach the client to do in the interpersonal effectiveness module. Would you say that's accurate?
- [32:53]
B
Yeah, I would say that as a therapist we're thinking about all of those principles when we're interacting with our patients, like how do we be most effective in this situation? And then we're also teaching them how to be effective with other people in their lives in similar way ways. What I think is really great about teaching somebody Dear man is that once they've learned Dear man, you can ask for that in your individual therapy sessions. If they're saying something in a really ineffective way, you can say, can you do that again? Can you think about doing that in a way that makes me want to give it to you? Using your Dear man skills so you can start to bring in the skills into the session and into the therapeutic relationship as well.
- [33:34]
A
Yeah, absolutely. I want to talk about the other three modules that we haven't really touched on as much that you mentioned. The mindfulness, I believe it was distress tolerance and emotional regulation. Could you maybe give us an example from each and about what that looks like in theory and in practice?
- [33:56]
B
So mindfulness, when DBT is not teaching people meditation, it's seven skills that are very concrete skills for how to practice being more mindful in your life. So we teach things like the skill of observe. How do you just observe? Just notice at the level of sensation what's happening in this moment. So we can observe our breath, we can observe the sounds in the room, we can observe the sensation of our body on the Chair. These are all examples of ways in which we can observe and we teach a skill called participate, which is how do you throw yourself fully into whatever it is that you're doing, Letting go of self consciousness and becoming one with this moment, whatever this moment is, whether it's something you really like, I'm throwing myself into this fun outing with friends, or it's something that you don't like, I'm throwing myself into this moment of cleaning my house and fully participating in that. So those are just some examples of concrete ways in which we teach mindfulness skills. Emotion regulation. There's a ton of skills in the emotion regulation module, a skill that is one of my favorites, though that probably changes any given day. But a skill that's designed to change the emotion that you're experiencing is something that we call opposite action. And opposite action, the gist of opposite action is to recognize that every emotion that we experience has an action urge, an urge to behave or act in a particular way, and that if we act in a way that is inconsistent with that urge, we can change our emotion experience. So, for example, when we feel anger, our urge is often to lash out, to be aggressive in some way, verbally, physically. And if we act on that urge, it's actually likely that our anger sticks around. Opposite action is the skill of identifying what your urge is to lash out at somebody and then to identify what's the opposite of that urge. Instead of lashing out, it's gently avoiding or it's being kind of, and then it's acting on that opposite urge over and over again until your original emotion goes down. And then in terms of distress tolerance module that is actually separated into two different categories. There's the crisis survival skills, which are how to get through what you experience as a crisis without doing anything to make the situation worse. Basically, how do you get through through it effectively? And the other category within distress tolerance is what we refer to as reality acceptance skills that actually what we're trying to do is not live our lives from one crisis to the next, that has the feeling that all we're doing is putting out fires all the time. So to counter that, the idea of radical acceptance is to say, is to practice accepting your life, this moment, the world, exactly as it is in this moment. And we have strategies for how to do that.
- [37:20]
A
And so just to clarify, going back to the structure of dbt, so you're going through these modules in a very linear fashion in the DBT group, and then in the individual DBT sessions with the therapist, the client is coming to the session with whatever challenges they're facing that particular week, they're talking about those. And you as the therapist are trying to incorporate these skills that they're learning into the treatment. Is that accurate?
- [37:44]
B
Yeah. Let me just though provide a little bit more context for the individual therapy session as well, because I think that provides a little bit more of the frame. We have a tool in DBT that we refer to as the diary card. The diary card is a piece of paper, an Excel spreadsheet. However, people do it now where we ask people to chart, self monitor on a daily basis a number of variables that are important for the treatment and also relate to the target hierarchy. So on the daily diary card, we ask people to rate, for example, their daily ratings of suicide ideation on a 0 to 5 scale. We ask them to rate their urges to self harm on a zero to five scale and then whether they engaged in any self harm in the last week. Yes, no. We asked them to rate whether they took their medications as prescribed, whether they drank, whether they used drugs, and then we asked them to rate different emotions, intensity of different emotions. So in an ideal universe, what happens is the person comes into session with their diary card completely filled out for the last seven days. The therapist with the patient reviews the diary card, takes a few minutes in the session to talk through what they notice. And so it could be going through the diary card and saying, okay, I see that most days you had suicide ideation of a 1 or a 2, but on Thursday your suicide ideation was a 4. I also see that you had a lot of urges to self harm, but no self harm actions, which is amazing. You drank on this day, you used marijuana, you're summarizing like what the week looks like. You're using the diary card and then any other information that you have to put in your mind, the target hierarchy for the session and to set an agenda, whether that's formal or informal. So the diary card will tell you, for example, whether there's life threatening behaviors that have to be discussed. Your experiences with them will tell you if there's any therapy interfering behavior that has to be discussed, including if they didn't fill out the diary card or they didn't complete it all the way. So you now have all the pieces of the puzzle coming together to say, okay, here are the different things that are falling into our target hierarchy that we have to address in today's session. Let's say you then identify what your topmost target is for the week. In this example, it could be the topmost target is the day that suicide ideation was a 4. Then as an individual therapist, what I'm doing is I'm assessing what that four means, what led up to that four, what they did when they experienced suicide ideation. I need to understand that so that we can together learn how to intervene and change that for the future. And our primary method for assessment is a tool in DBT called chain analysis, where we're assessing moment by moment, what contributed, what led up to that target behavior, what the consequences were. And we're doing that in order to identify different points of intervention. So the day that you had a 4 of suicide ideation, you didn't sleep well the night before, so you woke up really tired and cranky, and then your mom yelled at you because you didn't tell her that you were out the night before. And then you had to get to class and you got a bad grade. So all of these things are contributing. And then you're asking at what point did you start thinking about killing yourself and what did that look like? And so I'm filling in all the different pieces of the chain. And now let's figure out what could we have done differently in order to prevent suicide ideation from arising or getting to that level of intensity?
- [41:37]
A
That's super helpful. I think it sounds like both for the therapist and for the client and really being able to figure out the structure and the roadmap for any given session. Would you say that the more highly structured format of DBT makes it a treatment that is both appealing and also more feasible for clinicians that are earlier on in their practice or their training?
- [41:59]
B
It's hard for me to answer that fully because I this is how I've always done therapy, so I don't know an alternative, but I'm a big fan of structure. I think it is helpful as a therapist. I think it's helpful in keeping you on track to remembering what your goals are, not only for the session, but also keeping you on track for what are the person's goals in life. And I think so often we can get shaped into doing non directive therapy, like, let's just talk about what's going on for you. But then we find ourselves stuck because we're not actually making progress towards specific goals. And when you're working with folks who are high risk, they have a lot of suicidal behavior, they have a lot of self harm, or they have trouble holding jobs, or they're in and out of inpatient units, you need to have that hierarchy and that goal to really keep you focused on what matters the most.
- [43:00]
A
So I know that there's a pretty intensive and extended training in becoming an official DBT certified clinician. What would you say for people that aren't able to go through that training are some of the principles or strategies that any psychotherapist can extrapolate from DBT to apply to their work with patients with bpd?
- [43:18]
B
Before I go into that, I just want to say I'm all for people taking elements of DBT if they feel like that would be helpful. What I want to be very cautious about is clinicians not saying they're doing DBT when they're only taking a piece here or there. And I say that because I've had so many patients who have come to me and said, oh, I did DBT and I hated it, or I did DBT and it didn't work. But then you ask them what they did and it is not the treatment as designed. So as a clinician, if you want to borrow some things from DBT and incorporate it, go for it and be very clear that you are adopting an element of dbt, you are not doing dbt. Soapbox moment over. What I'll say is what a lot of therapists I think have benefited from is learning the skills.
- [44:13]
A
Learning the skills for themselves.
- [44:15]
B
Yeah. Or just knowing what the skills are and learning them themselves. Because I've done training for 20 something years and I will tell you that whenever I do training of clinicians and I teach the skills, there's never a time where people say, oh, this isn't useful for me. Everybody sees the skills as universally helpful. Maybe not all of them, but some of them as universally helpful. So I think if the therapists learn the skills, they will start to then see how these skills might benefit their patients in different circumstances. And they might in any given session say, you know, I learned this skill that I think could be helpful for you. Let me pull out this worksheet and let's talk about it together. And there's a lot of resources for learning skills. The other piece that I think clinicians can adopt from dbt, something that we actually didn't really get into, but I think is a core aspect of the treatment is to take a very compassionate and non judgmental view of our patients. So we have a lot of assumptions in DBT that we ask the clinicians, the therapists to adopt and model. And those assumptions include things like, the patient is doing the best they can, the patient wants to improve, the patient may not have caused all of their problems, but they're the ones that have to solve them. That the most caring thing a therapist can do is help a patient reach their ultimate goals. These are just a few. There's a lot, but all of the assumptions. They're kind of like therapy for the therapist. They're designed to help us have a more compassionate, nonjudgmental view of our patients in order to reduce what often gets in our own way and to improve our motivation to treat folks who are often quite difficult to treat.
- [46:18]
A
I think that's really helpful for all clinicians working with all types of clients. But especially given all of the stigma that there is towards individuals with borderline personality disorder, I think that compassionate lens and perspective is really crucial. So as we reach the end of our conversation, I would love if you could share a few resource suggestions. We'll also link them in the description for the episode for any clinicians who might be interested in learning further about dbt.
- [46:45]
B
Yeah, so the book that came out just a few months ago with my co author Jesse Finkelstein is actually designed as more like a self help book to teach anyone who's interested in learning DBT skills more about them. And it's a very user friendly, includes some illustrations and some really specific strategies for how to learn and practice the skills that could be useful for anybody who wants to learn the skills themselves, but could also be useful for anyone who's teaching somebody DBT skills and wants to use it as like an adjunct to the skills training manual. There is of course, the Linehan manuals. There's also a couple of books that are written by other DBT experts that some people might find a little bit more user friendly or updated since Marsha Linehan's 93 book. One of them is called Doing Dialectical Behavior Therapy by Kelly Kerner. Another is a book by Charlie Swenson, DBT Principles in Action, which is a little bit more user friendly, as I said, than the original manual. So I encourage people to look that up. And then there's a number of different training companies that offer one day workshops, multi day workshops in dbt and I encourage people to explore those if they're interested in more extensive training.
- [48:07]
A
Amazing. So we will drop all of those resources in the episode description. I think that is close to all of the time that we have today. I just want to open the floor for you a little bit, Dr. Risby, if you have any points that you would like to mention that I didn't touch on. I think we had a really great comprehensive conversation. I know that I certainly learned a lot. Hopefully our listeners did as well. And I certainly did not cover everything that there is to know. So if there's anything you have left in mentioned, would love to give you the floor for that.
- [48:35]
B
Well, I really appreciate this opportunity. I will say, you know, when we're doing the training like the traditional training in dbt, that was the model that was originally established by Linehan, involves clinicians coming together for a full five day training, 40 hours of training, and then six months later coming back for another 40 hours of training. And they're still training models and companies that do that model. But why I'm illustrating that is that 80 hours of training and practice in between. And here you and I spoke for an hour and I'm trying to give, you know, a glimpse into what DBT is. It's a complex treatment and I want to not mince words about this because even though I think sometimes, especially people that have been trained in other modalities have a thought that, oh, behavior therapy is simple, not so complex. I think DBT and I actually think behavior therapy is quite complex when you really focus on precision and clarity. So DBT is complex. You're not going to learn it in a week, you're not going to learn it in a one hour overview. Really encourage you, if this is interesting to you, to seek out more resources and to recognize that it's a lifelong practice and that that's why consultation team exists. I'm always striving to get better myself every week and with every person I treat.
- [49:57]
A
I think that is a great note to leave off on. So thank you so much for Joining us today, Dr. Rispi, and thanks to our listeners for tuning in. And we will be back soon with our next episode in the series, Mentalization based treatment with Dr. Carla Sharp.