Podcast: The Power of Dialectical Behavior Therapy

Jeff talks to Dr. Anna Precht about dialectical behavior therapy, or DBT. They discuss the logistics of what DBT is, and what makes it different from other treatment options such as CBT. They mention ways that clinicians can become properly trained in DBT, and how individuals seeking treatment can find properly certified clinicians. They also discuss the history of DBT, its current applications, and what its future may look like.

Anna Precht, PsyD, is a clinical psychologist and the program director of McLean’s adolescent dialectical behavior therapy program for young men. She has extensive experience treating adults and adolescents using DBT in both individual and group settings. Dr. Precht is particularly interested in the treatment of borderline personality disorder and self-injurious behaviors.

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Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Hi there, and thanks for joining us. My name is Jeff Bell. And on behalf of McLean Hospital, I’d like to welcome you to this episode of our educational webinar series.

Our topic today, dialectical behavior therapy, or DBT. It is one of the most effective and versatile mental health treatment options available today, and yet for all of DBT’s success in the treatment of all kinds of mental health conditions, it is still widely misunderstood.

So, our goal today is to provide an overview of just what DBT is, how it works, and what sets it apart from other treatment options. And we have lined up the perfect guest to do all that for us.

Dr. Anna Precht is a clinical psychologist and program director at McLean’s adolescent dialectical behavior therapy program for young men. She has extensive experience treating adults and adolescents using DBT in both individual and group settings. Anna, thanks so much for joining us.

Anna: Thank you for having me. It’s good to be here.

Jeff: Well, we’re thrilled to have you, and we have a lot to cover today. So, before we dive in too deeply, I thought it would make sense to ask you to describe in the most general terms what we’re talking about when we reference dialectical behavior therapy. Can we start there?

Anna: Sure. In a broad overview kind of way, DBT was initially established to treat borderline personality disorder, and it blends behavioral principles with mindfulness strategies.

It teaches skills for people to manage their emotions and their behavior, and it has a variety of different components, including individual therapy, group therapist support, and the availability of phone coaching in between for the skills use.

Jeff: So from what I understand, the history of DBT itself is pretty fascinating. Can you walk us through the evolution?

Anna: Absolutely. So back in the 70s, Marsha Linehan was a psychologist in Washington, and she wanted to research how to treat emotionally dysregulated, very complicated patients that she was seeing in her clinic.

And she wanted to apply cognitive behavioral therapy, classic kind of behavior techniques to this very tough population, suicidal, self-harming, multi-problem adults. And what she found when she was applying standard behavioral therapy to these people of problem-solving was that people would not end up feeling better. In many cases, they’d feel worse.

So, for instance, if a patient came to the clinic and said, “I lost my job this week, and I self-harmed, and I couldn’t get out of bed to go to class, and I’m worried about my relationship.” And she went in with a standard problem-solving approach of, “Okay, let’s talk about what to do. Here’s how to solve the problem and get past the breakup and get out of bed.”

People’s knee-jerk response was, “You’re not understanding,” and like, “It sounds like you think I’m the problem or there’s something wrong with me that I’m not doing these things.”

So, Marsha changed her course and decided to say, “All right, we’re going to try something more humanistic in its approach of understanding and validating more warmth.”

And so she changed course and said, “All right, we’re going to research this task.” And so the same people would come in and say, “I self-harmed. I’m having suicidal thoughts. My emotions are all over the place. I lost my job. I can’t get out of bed.”

And the therapist would say, “That sounds really hard. Your life is feeling chaotic at the moment. You’re really suffering.” People would feel more understood and connected, but then they would end up getting frustrated because like, help me solve my problem. Why aren’t you helping me to figure out what to change?

And so that was the kind of breeding ground for Marsha Linehan saying, “We need both. We need the problem-solving push when people are suffering like this, and it needs to be done with validation and compassion and warmth.”

And that’s where this idea of dialectics comes in of things that seem opposite coming together and weaving them in such a way with some flow and movement on the part of the therapist that then can help people change more effectively. And then woven into that, as we’ll talk about, are the specific skills that get taught along with practice of Zen mindfulness.

Jeff: In terms of applications for DBT, those have expanded greatly over the years as well, have they not?

Anna: They have in really exciting ways. So initially formulated for borderline personality disorders, like, all right, here’s the treatment for BPD. And the research started picking up steam for that diagnosis.

And over the course of time, since the manual came out in the early 90s, people have been saying, “This makes a lot of sense for substance use disorders, for some eating disorders, other kinds of problems with emotion regulation.”

And the skills are so practical, and they’ve been augmented for teenagers and for couples and for all kinds of difficulties that people encounter.

And I think that process is still continuing as people say, “Well, what about treating autism spectrum disorders? What about this? What about this?” And it’s building efficacy across the board.

Jeff: Where would you put it in today’s spectrum of tools available to psychologists, for example, today?

Anna: In terms of tools available, in terms of training or?

Jeff: In terms of popularity, prevalence of use.

Anna: I think it’s certainly gained in popularity and prevalence since I started training in it over 15 years ago. It’s much more widely accessible. Trainings are much more accessible to clinicians. It’s gaining in popularity as the research continues to get bolstered.

And there are still lots of areas in the country, in the world where it hasn’t been as picked up. There aren’t the providers that are needed in a lot of areas.

Jeff: And we’ll circle back to this, but I think one of the fascinating things about DBT is it’s being used proactively for mental wellbeing these days as well.

Anna: The skills make sense. So, I’m the program director here of a program for young adults and teenagers, and not just boys and men, we’re much more gender-diverse and fluid, but kids come to this program, parents are learning these skills as part of this program.

And frequently people say, “Why? Why isn’t everybody being taught this?” There’s so much utility and application of skills for how to slow down and regulate one’s emotions and communicate more effectively. And I think people are starting to realize that. And I’ve heard about all kinds of school-based integration of DBT skills.

Jeff: Let’s talk about those DBT skills. There is a set that is commonly associated with DBT. I assume that pretty much stays consistent across DBT treatment?

Anna: There are. So, there are four main modules of treatment that get taught in skills groups that are part of when somebody is entering into a DBT program. The core component, the cornerstone of the treatment really is the mindfulness practice.

And it’s not just like be mindful, right? Because like people say, “But how? But what do I do to be mindful?” And DBT says, “Here are specific things to do. Here are specific ways to practice in a non-judgmental way, slowing down and being present.” And so that’s really the core component of DBT.

And we weave it into the rest of the modules that include interpersonal effectiveness, teaching people how to ask effectively for what they want, how to maintain relationships, how to assert their self-respect when needed, and how to do all three.

Another module is emotion regulation, which is like the meat and potatoes of how do you experience emotions without getting totally swamped by them and without totally pushing them away and neglecting them.

And then the fourth module is what we call distress tolerance of how to tolerate profoundly difficult crises, emotions, urges, how to get through it without necessarily like regulating the emotions themselves, like how to get through painful situations without making it worse, which sometimes people do in the height of their emotions.

Jeff: What does the integration of all of that look like? Do folks who are going through DBT treatment learn the skill set one by one?

Are they sort of masked together as they’re working through the treatment, or how does that work?

Anna: So, when somebody signs up with a DBT therapist for standard outpatient DBT, they have an individual therapist that they meet with to identify their individual goals, and they track their emotions and their behaviors and their urges and their skills use every week with their individual therapist.

And then as an adjunct to that, they attend a DBT skills class or group where they learn all of those modules. And each week, it’s a skill, and there’s an assignment of practice, and then there’s the review of the homework from the previous week of really strengthening the muscles of these skills.

Jeff: I want to drill down a little bit more on the mindfulness component, because that’s so key, as you’ve talked about here. You mentioned the value of being present and the value of self-awareness. Can you speak a little bit more to both of those?

Anna: I mean, it’s the linchpin of the treatment, because if somebody isn’t aware of what’s going on in the moment, they don’t have the ability to then steer it differently.

I’m thinking of it like, when I’m driving in a car, and I’m going 10 miles an hour during- in a very narrow street where there’s construction and other cars coming at me, going slowly and being present helps me then pay attention to what I need to do to steer.

If I’m going 75 miles an hour, I have fewer choices, I don’t have the ability to then steer differently. But when I’m paying attention, and here, options open up.

And so that’s true with my emotions, my thoughts, whatever people might be saying at me, I can move more slowly in a way that gives me control of what I do next in my response, either to what’s going on internally or externally.

Jeff: This is part of a larger trend, is it not, to incorporate the mindfulness component into much of the psychological tools that are being used today?

Anna: It is. And the research on mindfulness is abounding as well. And I remember at one point I was, I think I was reading something that said, “Doctors are going to be talking about mindfulness in 50 years the way they talk about telling their patients to quit smoking or eat vegetables or exercise now.”

That mindfulness is really such a crucial component of psychotherapy, but also, as you said, kind of the broader wellbeing.

Jeff: We mentioned in our lead-in to you that there are a lot of misconceptions out there about DBT. What do you find are some of those more common misconceptions?

Anna: You know, I think there’s a few, the first ones that come to mind when people hear about DBT, and they haven’t gone into it as far or learned about it as much. They think of it as being incredibly superficial and just manualized in a, “if you have this problem, do this thing.”

And I think for some people, they hear that and go, “My life is more complicated than that. It’s not a one-for-one ingredient, like, don’t tell me to take a bubble bath if like, I’m having urges to harm myself” kind of thing.

And DBT really is much more complex than that. It is not a superficial treatment. There are ways that a therapist and their client get into very heavy, difficult things.

I think another common misconception is that any therapist can do DBT, just read the book and do it, like, “Oh, I’ve read the worksheets, I learned the skills. I know about mindfulness. Now I’m prepared to do DBT.” And that isn’t the case.

I mean, there’s very specific training that goes along with this for how to provide this treatment in a way that’s more than just the didactics of the skills worksheets. It’s how to do the session, relate to the person in front of you.

Also, how to provide coaching in the heat of a crisis, between sessions, which is also a fundamental piece of DBT, that a therapist provides the ability to say like, “Oh, you’re in it now. You learned this skill last week. I’m going to walk you through using it when you need it most.”

And so I think a common misconception is any therapist can do that quickly and easily. In terms of other things... Or that it’s only for borderline personality disorder, that if somebody needs DBT, it’s just because they must be suicidal, and that’s not the case.

Jeff: We’re getting a number of questions coming in, and I want to weave them into our conversation as we go today, Anna.

And one of them I think is timely as we progress here with what DBT is and is not, a viewer would like us to kind of compare and contrast DBT to what we commonly know as CBT, cognitive behavioral therapy.

Anna: Yeah, absolutely. As I mentioned, DBT is closely related to CBT. In fact, the original manual that Marsha Linehan published is called “Cognitive Behavioral Therapy for Borderline Personality Disorder.”

So CBT is baked in, and it’s an expansion upon it, that CBT focuses heavily on the C, the cognitions or the thoughts. DBT takes those behavioral principles and looks more closely at the emotions, the emotion experiencing.

And then it also adds in specific skills about behavior and tolerating distress and leaning heavily on acceptance as a strategy, like I said, in the birth of DBT, it’s like not just the, “I’m going to change my thoughts” piece, but “I’m going to practice acceptance and mindfulness as well.” So it’s different. And there are some overlaps, certainly.

Jeff: I want to start talking a little bit more about the mechanics of DBT, because I know that’s going to be very germane to our conversation as well.

Individual versus group settings, inpatient versus outpatient, therapist-patient dynamics, expectations, can you walk us through some of those aspects of the DBT process?

Anna: Yeah, so I’ve done DBT in a variety of different settings, outpatient, now residential, inpatient, partial programs. And there are core pieces of it, like I said, the skills remain the same, mindfulness remains the cornerstone of the treatment, whether it’s in an outpatient setting, inpatient setting, and there’s different ways of practicing it.

So in DBT, on an outpatient basis, like I said, it’s the individual therapy, the group skills class, the availability of skills coaching between sessions, and then that consultation team, that group for providers to get support and stay on track, and that’s the outpatient model.

Here in my residential program, it’s not just one session a week or one class. In the residential piece, it is all DBT all the time. And every member of the staff is trained in these skills, is speaking that language.

And so, when somebody comes to this program, it’s not like they’re doing, I use the example of like learning a language, they’re not taking a once-a-week language class. It is full-on immersion, and they are learning to speak it as everybody else is speaking it around them. And so we have groups daily and throughout the day.

And the coaching is offered by the staff here. On an inpatient unit that is much shorter term, there is specific skills that are helpful in a more like targeted and acute way. If somebody is going to be on an inpatient unit for a very short time, whether it’s three days, five days, or a week, inpatient units often want to send these people home with like, okay, skills for managing the crisis.

It’s like, what are the handful of skills that you want to walk away with so that you don’t get into the crisis that maybe got you here. And so it’s adapted depending on the setting and the population that’s being treated.

And there are other pieces, like I mentioned, the diary card, where people track their emotions their behaviors and their urges to see how to understand what leads them to those kinds of painful places. Does that answer the- the question had multiple different parts to it.

Jeff: It does. And we’re going to actually walk through some DBT and action examples in just a couple minutes, I think will help make things more concrete as well.

I do want to ask you about this. I’ve read that DBT is often used in conjunction with other mental health treatments. Is that the case?

Anna: Well, absolutely. I mean, I’m thinking of medication as a mental health treatment that for a lot of people when they’re in crisis, when they’re severely depressed, or their anxiety is crippling, or maybe they have ADHD, they need medication to manage those things.

And maybe they’ve been using psycho pharm until they get to DBT, and they start DBT, and the psychiatrist and the therapist work together to figure out, “Okay, what skills does this person need? What can get managed by medication?”

And I mean, Marsha Linehan, I think, used to say it like, “Skills not pills. Let’s try to get people more on using their skills muscles.” And so what we often see here is as people’s skills get stronger, their need for medication goes down, and so doses get lowered or eliminated.

And for certain conditions, like it’s important to maintain medication. I’m thinking of like bipolar disorder that gets managed with medication, and then the skills can be an adjunct to that.

Jeff: We have questions coming in about age, and let me just tap into a couple of those here. One here is, is DBT appropriate for older adults, say over 65 years old?

Anna: There’s some good research on that. Yes, absolutely. And anecdotally, I’ve worked with many people over 65, and it might be like, we need to change how the teaching of the skills happens, whether that’s the type of group that people feel like they can connect with or maybe it’s certain ways of teaching the skills that make sense.

The examples I might use with a 65-year-old as I’m teaching are going to be different than when I’m working with a 15-year-old. And the skills remain the same, and we’ve seen great benefit.

Jeff: So, the flip side of that spectrum, is there a recommended minimum age for DBT therapy? Is it appropriate for kids and teens?

I know you work with teens, so I can answer that second part, but what about younger kids?

Anna: So, I do specialize in working with teenagers. And DBT has been adapted to working with younger kids, with children.

It’s, again, it’s an adaptation, and a lot of it is parenting work with the little ones, that parents need to learn the skills, need to learn how to communicate and maybe respond to behaviors differently. And then the skills get taught in a way that’s more accessible to little kids.

Jeff: I think it would be really helpful if you’d be up for this to have you walk us through a particular hypothetical example.

Let’s say somebody comes in looking for treatment for depression and is interested in being treated with DBT. Can you just take us through that process pretty much from start to finish, what that looks like?

Anna: Sure. I’m imagining on an outpatient basis, right?

Jeff: Sure.

Anna: Kind of the most typical. So if somebody says, “All right, I’ve heard about this DBT stuff, and I’ve heard that it’s really helpful and pragmatic, and, you know, my providers have recommended this to me.”

Finding the DBT provider that practices comprehensive adherent DBT is piece one and asking important questions of that therapist in the interviewing process, questions like, do you provide skills coaching between sessions?

Do you sit on a consultation team of other providers where you get support and consultation about the patients you treat? Do you have a separate skills group for your individual clients? Those kinds of questions.

And when you find a provider that is part of a comprehensive, adherent DBT team, you get started with mapping out goals for treatment and really digging into what are the things that need to change?

And this is different from other therapy modalities. We get specific, and we get structured, and we say, “All right, we’re going to track these things, and we’re going to talk directly about them in an organized fashion.”

And then we’re going to say, “Okay, we’ve got to map out what is your hopelessness looking like, what is the sadness looking like? How often are you staying in bed for days at a time or showering, like, are you showering if you’re severely depressed? Are you having suicidal thoughts?”

And then when somebody comes to a DBT session, it’s organized. I start most of my sessions with, “Okay, what’s on the agenda today?” And there’s a clear hierarchy of how we talk about things because if somebody, I don’t know, got a D on a paper, and they also separately had suicidal thoughts, we’ve got to talk about the suicidal thoughts in an organized way.

We’ve got to prioritize certain things over others and understand like, if you are engaging in life-threatening behaviors, that’s going to come first. And so there is this structure for how to approach what we call targets or target behaviors in a DBT session.

And I let people know the first time I meet with them that this isn’t the kind of therapy where you come in and you talk about whatever’s on your mind. We’ve got a job to do, and we want to stay on track with that because if that depressed individual is so depressed that they’re hopeless and suicidal, like, we got to take that job really seriously.

And so the session gets structured around the diary card, the emotions, the behaviors over the course of the week, skills use or not, and then we put a microscope on those behaviors, on those things that came up over the week, and we do something called a chain analysis, a behavior chain analysis.

And I walk through with people, how is it that you got to this particular behavior? Maybe it’s using substances to numb out or get relief from painful emotions, and what are the links in the chain that get you there? What are the problem links? And where’s there room for a different avenue using skills?

And then that person also goes to a skills group once a week, and they go, and it’s more like a class. They practice mindfulness, somebody’s teaching it, they’re reviewing examples, there are worksheets, homework assignments, and that’s highly structured as well.

Jeff: And so what you’ve described is for an individual came in for depression, would things look very different if the challenge was substance misuse, for example?

Anna: Well, the core components of like the individual session, the class, the coaching, the tracking pieces, all those remain the same, and the targets might be a little different. So for the person who isn’t getting out of bed because they’re so depressed, that the skills needs might look different than the person who is feeling out of control of their substance use.

And DBT in its continued adaptations has a specific treatment for substance use disorders of like, “Okay, we’ve got to talk about how- What’s your relationship with sobriety?”

Or, “What does that look like when you relapse?” “What specific skills are necessary for that difficulty?” And that would then come into the individual therapy or the skills group or the coaching, but those core components remain the same.

Jeff: Got a couple questions come in about finding a DBT therapist, and folks are referencing the fact that that can be very difficult. Do you have any suggestions?

Anna: Oh, it can be. And this is one of the things that the DBT community is very much concerned with, like, we got it, we know this treatment works, we want to make it more available, not just in cities, and not just in the United States, and not just, like, just, just, just, because it hasn’t caught on in the same prolific way that I think it’s going to keep doing.

And so, for finding people, there are different resources. So, the Linehan Institute that really trains up therapists. I mean, actively therapists can go there and find trainings. And there are other organizations that do trainings as well. They often have lists of resources of programs and clinicians.

There are, I know Florida for instance, has its own Borderline Personality Disorder Association, where there’s a whole resource guide for how to find DBT therapists in that state. And I mean, I think there are people out there, but it’s hard to get to them.

So, it’s calling the insurance panel and saying, “Give me the list of people who say they’re trained in DBT,” and then interviewing them. And that’s the process that people typically go. Or calling McLean Hospital and saying, “I need help finding a DBT therapist. What do I need to do?”

Jeff: You just touched on something very important, interviewing that potential therapist. What are some screening questions that might make sense to ask?

Anna: Well, I mean, I think the big ones, like I mentioned, are, are you sitting on a consultation team with other DBT providers? Have you been trained in an intensive way in the provision of DBT? Is there a skills group?

Do you offer coaching? What might be some limits around coaching? How does, what does that actually look like? Those are the big ones. And like, do you have your clients use diary cards?

And then, I think, it is a rightness of fit because DBT therapists, we have the structure, we have the skills, and we can range in wild ways in terms of style and personality as all therapists do, and then it’s the rightness of fit.

Do you have expertise in substance use disorders? Have you treated people who are over 65? And, oh, you have? what does that look like? How is that different from when you’ve treated younger adults?

Jeff: A viewer would like your thoughts on self-taught, self-paced workbooks when no therapist is available.

Anna: You know, I’m of the mindset of “do what you can, do what works.” And absolutely, there are plenty of places in this country, in this world where there isn’t DBT in this comprehensive way available.

And so, people do what they can, and there are videos online where you can get some skills. There are worksheets and workbooks, Zoom has become, I mean, as annoyed as we might get by it, it does open up doors, like having this conversation today, and maybe there are ways to connect to other areas.

Licensing across state lines has changed in light of the pandemic, where people can provide treatment to areas where there aren’t clinicians available.

Jeff: Let’s talk for a moment or two about the role of families in DBT support. My understanding is that there might be some formal roles in terms of the actual practice that’s being put out there for the treatment, and then maybe some more informal support roles as well. Can you speak to those?

Anna: Sure thing. I mean, I view families as integral. I mean, and it can span from the kids and the teenagers and the young adults who are maybe in college and still have a relationship. But I’m also thinking of the 65-year-old who needs DBT and has adult children or siblings who are interacting with them in a bigger way.

And the family members need support too when somebody that they love or are supporting is struggling in these kinds of ways. I think it’s helpful, in some cases, even like crucial that family members get skills as well.

So, for instance, in treating young adults here who often have close relationships with their parents, their siblings, we have parents skills training that we require because if the environment doesn’t change in a more skillful way, it is a far, far steeper uphill battle for the individual client to then make the change, right?

And so there are organizations that offer skills and support to family members, spouses in getting DBT skills, and like reading the books, learning the skills to be able to reinforce it, I think is crucial.

As DBT also expands, I think there’s more opportunities for skills groups that are specific to parents, spouses, siblings, children. And I only expect that to continue to grow as it gains in popularity and continues to show efficacy.

Jeff: So, on this topic, another question to weave in here. How do you encourage a loved one, especially one who is aware of DBT, to focus on their DBT skills when they’re not able to do so on their own?

Anna: All right. This is a question for the ages, Jeff, truly. I mean, saying to somebody, “Use your skills” doesn’t typically work, right? Like, why can’t you just use the things that you’ve been learning, like do it differently, I see you suffering it. It is so hard.

And that is one of the reasons that I think family members need support too, they need skills to help them with their emotions when a loved one is struggling in these ways, because as much as we want to encourage and support, in most cases, we are limited in our ability to force somebody to engage in using skills or participating in therapy in a more helpful way.

And so, I think communication with your loved one’s therapist can be helpful because there might be individually tailored ways, that something like, oh, this might be an avenue for communicating with somebody and like really helping them to use skills better.

Jeff: Another very specific question here. Any best practices or suggestions for applying DBT to individuals with intellectual developmental disabilities and co-occurring mental health?

Anna: This a tough one as well, because when it comes to the skills classes, the worksheets, as much as they aren’t incredibly rigorous, and they do require some ability to understand, grasp, and apply the skills.

And so DBT has to be changed to meet the needs of the person where they are. And that’s true for learning difficulties or processing troubles, attention difficulties. But that comorbid issue I think comes up a lot.

And then it’s like, maybe rather than having a group or a class setting, maybe that person needs individual like tutoring of the skills in a way that meets them where they are in terms of their ability to grasp and apply the skills.

Jeff: Wanted to circle back to something we touched on early on in the conversation, and that’s this notion of using DBT proactively for someone not diagnosed with a mental health condition, what does that look like today? And if I’m interested in pursuing that, how do I go about doing that?

Anna: So, I want to make sure I understand. So, if I don’t have a diagnosis, and I’m like, “Ooh, this sounds kind of interesting, I want to like learn more about this and apply these skills to improve my life.”

Jeff: Exactly. I’ve not been diagnosed with depression or OCD or a particular mental health condition, but what I hear about DBT sounds fabulous, and I think it could help build my own skills. Can I go into therapy and learn these skills?

Anna: Absolutely. And I’ve had people come to me with that of like, “Okay, I’m not self-harming or abusing substances or binging or purging,” whatever the behavior is, “and I think I could regulate my emotions better. And I understand DBT is a good source for learning how to do that.”

And then I might change, as the provider, how I provide DBT, so it’s not like, “Okay, you need to do this, this, and this,” but we can have a conversation in a more DBT-informed way that doesn’t strictly adhere to the structure that is typical.

And that might be an individual kind of tutoring, discussion too, of, okay, is it your relationships where you want to improve these skills or is it like your irritation or increasing joy? What is it you want to do?

And for a lot of people, I think, like we talked about, reading the books, going to the resources, for that person might be enough.

Jeff: You also touched on this earlier, but I think it’s worth circling back as we’ve had questions come in on this front as well. Clinicians looking for more training, are there particular certification programs?

You mentioned one earlier. What else is available to a clinician who is viewing this webinar right now and wants to learn more and get trained?

Anna: I think there are a number of centers who have the certification as a program that also provide training and the ability to do that, again, in that adherent sort of way that sticks to, this is the treatment that we know that works.

And for those providers that are interested in DBT, I mean, I’m so excited, like I, and I want to tell-

Jeff: I can tell.

Anna: I’m like, “I’m a DBT geek.”

Jeff: I love that passion is just coming through, it’s very cool to see.

Anna: Well, I mean, I think reaching out to DBT providers who have had that training, because they are probably hooked into other networks and know of the resources to be able to get that training. And places like McLean Hospital have trainings in DBT, like there are places depending on geography or specialty.

And again, Zoom helps a lot. I’ve attended Zoom trainings about, you know, DBT for eating disorders or trauma, whatever it might be. So, I think there’s a lot of flexibility when people reach out and get into the network of DBT-trained people.

Jeff: I’m curious, is DBT mainstream enough that it’s working its way into the academic environment and training through college and master’s programs, for example?

Anna: Here and there, I think it depends. I’m hearing more about it, and it is a more intensive kind of training, and so you’d need a specialized kind of graduate program. And they are out there certainly at the PhD level, PsyD and the master’s level, where they offer more training in that.

And then it’s like how to get the practicum, the internship, the externship to be able to get the supervision and the practice in doing the treatment that’s necessary. But, again, we’re getting there, and more to be done.

Jeff: Well on that front, where is the frontier for all of this? Where do you see DBT going in the future as it continues its evolution?

Anna: Oh, well, I mean, starting with this webinar today, creating this DBT utopia of like everybody knowing the skills and using mindfulness as a core muscle.

Jeff: Excellent.

Anna: But I think as, again, like I said, the research continues to be strong. People are continuing to get the training that they need. And there are a lot, there are conditions out there that it hasn’t been applied to.

And so frequently I’m hearing, “Well, but what about this population? How about this population? What do we do here?”

And it’s that next generation of people who are in grad school right now who are going to get excited about DBT, use the skills themselves, and then say, “Okay, I want to push the limits and see where I can take this for how it can be helpful.”

Jeff: Let me weave in a few more questions here as we’re looking at the clock getting a little closer to our end time here than I had imagined at this point. How can you use DBT to manage suicide ideation and suicide behaviors?

Anna: Well, that’s what it was designed for, and it’s hard work, and it is heavy lifting. And so, what I do when I’m working with somebody that struggles with that is like, we have to talk about certain skills to manage those thoughts and behaviors. We do that chain analysis of how is it that you get from losing your job to think about ending your life?

We’re like, “How do we help increase the skills for that chain to go differently, to build the commitment of, okay, as bad as it can sometimes get, how do we help you to take suicide off the table as an option and start doing other things more skillfully? And in working with these people, the use of phone coaching between sessions is a big piece of it.

That if somebody in the middle of the week between meetings with me is having the urge to engage in suicidal behavior, they’ve got to call me up for coaching, and say like, “I am in the thick of it, and I don’t know what to do because I can’t remember what I learned in skills group last week.” And I say, “Okay, here’s what you do step by step.”

And it is the practice of using distress tolerance, being able to be in pain and not make the crisis worse. And then over the course of time, being able to regulate emotions or communicate what’s needed to steer that chain in a more adaptive and balanced kind of way.

Jeff: We talked early on about mindfulness as one of the components of DBT, and you just touched on distress tolerance. I think we’ve got enough time that I wanted to see if you could give us a little bit more on interpersonal effectiveness and emotion regulation.

What should we know about those two components and how they factor into this whole process?

Anna: Well, I think when people struggle with their emotions, for example, anxiety, that if somebody gets incredibly anxious and says, “I can’t ask for what I want. I can’t ask for the raise at work,” and they don’t know how to do it, the emotional regulation and the interpersonal effectiveness go hand in hand, and we figure out what skills are necessary.

Sometimes people genuinely don’t know how to structure what to ask for, what they want to, and there’s a skill for that in a, again, structured kind of way of walk through these steps to increase the likelihood of being more effective in the request.

And like, what do we do with the anxiety, right? Or the sense of worthlessness or hopelessness or shame of, “I don’t deserve a raise.” Well, we’ve got to do some of that work too, of okay, looking at the emotion and saying, “What’s valid here? What makes sense? Does this fit the situation?”

And then how can I experience the emotion and let it pass while weaving in mindfulness of, “Okay, my boss isn’t yelling at me in this moment, right now, I’m asking the question.” That’s like coming back to the moment rather than jumping far ahead to my feared or catastrophic outcome.

And so, I think they fit together of, how to ask for what I want, what to do with my emotions, how to slow myself down?

Jeff: Let’s talk expectations. What can someone expect to get out of therapy, and to what degree can they expect to turn around their mental health challenge going through the DBT process? And I realized that there’s not one answer that fits all here.

Anna: I was going to say, I wish I had the equation for, you know, like, this is the timeline. I wish it were like a recipe of “bake the cake for this many minutes, and then it’s done and like, you’re ready to go!” But I think circumstances and people’s individual struggle can change the course dramatically.

In a DBT class, a typical outpatient group, it takes about six months to get from the beginning to the end, and people typically go through twice. So that’s kind of this, that’s what the research is typically, that’s the standard model that it’s based on.

And it depends, it depends on life circumstances, it depends on what the presenting problems and symptoms are. It depends on the environment and the kinds of support a person might have. So, it is hard to say, which I wish I had a better answer.

Jeff: Well, that’s fair, that’s fair all the way around. You mentioned the importance of fit, and it dawns on me listening to you talk about the relationship, the dynamics I should say, between a therapist and a patient, that can be especially critical in DBT.

What might be a flag for a patient that when they’re in the process and that they’re feeling like perhaps this isn’t a good fit, A, what might be the flag, and B, what should they do about that?

Anna: Well, I think it depends. for a lot of people I know, they have got a kind of spidey sense of, oh, that this, that’s not right, that feels like too much. That if a therapist is like disclosing too much about their personal life, for instance, right?

And in DBT, we are radically genuine, and I am, sometimes I say, “All right, I have this example that I can use from my life about using skills that pertains to this,” right? And I think for some people it depends on how far that goes.

Red flags... Availability is one thing that comes to mind because coaching is such an integral part of the treatment. But I think for a lot of people, the rightness of fit is more of that intuitive like, “This person gets me, and this person knows how to treat the things that I struggle with.”

And that’s the part of the interviewing, like ask those questions directly, and then maybe see the fit. Do I feel comfortable talking with this person about these incredibly sensitive matters? Do I feel shut down or invalidated in more painful ways? Age, race, gender, I mean, these play into it too for people.

Jeff: You work with teens. We’d be remiss not to ask you about what some of the lessons are that you’re learning from these teens as you do your DBT work.

Anna: Well, my “Mario Kart” game has improved.

Jeff: I’m glad to hear that.

Anna: Because I think in working with teenagers, therapy can sometimes look different, it might be more active, and it might be listening to some music, and like, I tend to listen to music that was popular when I was a teenager, and so one of my skill sets that has improved over the course of time is I know a little bit more music that’s popular these days with the kids.

Jeff: Just an added bonus of your work, huh?

Anna: Oh, right. It is. But I think in working with teenagers, one needs to be more genuine, I think authentic because teenagers can smell it a mile away if you’re inauthentic. And that feels like a piece of it, that being real and connecting with a teenager is a different skill set.

Jeff: I want to be sure to ask you about resources before we wrap up our chat here today. Are there books that you recommend, organizations that you would point people to?

Any other resources for people looking to learn more about dialectical behavior therapy?

Anna: There are absolutely books, one of my favorites is written by my colleagues, that’s “DBT for Dummies.” I mean, it’s a primer, like you want to know what the basics are, that has it. And that’s a good entry point.

And then there are DBT books for couples, “High Conflict Couple” is the name of another book that’s good for family systems and couples that struggle with some of these difficulties.

Marsha Linehan’s memoir is a good entry point and like, what did it look like for her? Because she came out a number of years ago in “The New York Times,” and said she had the struggles that she was treating when she was a young woman.

And so that might be a different point of interest for people who are curious about what DBT looks like and what its founder, kind of her experience. Mindfulness, plenty of books on that. Jon Kabat-Zinn’s “Wherever You Go, There You Are” like is a classic.

Jeff: It is.

Anna: I mean, there’s a host of books out there, sure.

Jeff: And finally, as we wrap things up, Anna, you are so passionate about this topic, and I love that. I want to give you the last word.

Take a few minutes and share with us any final thoughts, maybe something we didn’t touch on today that you would’ve liked to have part of the conversation. I don’t know, what stands out to you at this juncture?

Anna: Oh, man, like you have asked all of the questions and steered this conversation and in such a lovely way.

Jeff: Thank you.

Anna: So I appreciate that. I think we got to all of the major points, and I think my encouragement to the audience today is if you’re a provider and you’re interested, go, do, learn more. It’s a really cool treatment that works. And frankly, my life as an individual is better because of DBT skills that I learned as a trainee.

And if you’re a participant who is struggling, and your emotions feel out of control, if you feel like it’s a rollercoaster, or that your emotions are in the driver’s seat in a problematic way, reach out and see what DBT providers are in the area because this stuff works.

Jeff: Anna, thank you so much for your time. We could go another two or three hours. We’re going to have to have you back on the series again, okay?

Anna: Thank you so much, Jeff. It’s been fun, it’s been a pleasure.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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