hey everyone welcome to the drive

podcast i'm your host peter etia

hey sharin it's great to finally meet

you not in person but uh better than

being on the phone i guess

yes same here so um

you know people on this podcast have

probably heard me in a couple of

episodes reference this thing called dbt

uh i've never really gone into much

detail

about it but it's something i've wanted

to obviously have a dedicated podcast

around and now we're finally going to

get to do that so

i mean

i guess maybe we can just start by kind

of defining what it is a little bit

before we get into its history

uh its founder

your your involvement and things like

that so if you're at a party and

somebody said

shireen i i heard that you know you're a

dbt therapist

and a practitioner uh can you tell me

what that is what would you say

sure so dbt stands for dialectical

behavior therapy

abbreviated dbt and it's a form of

therapy or a form of talk therapy

that is

largely

inspired by cognitive behavioral therapy

also abbreviated as

cbt so we often say that dbt is a form

of cognitive behavioral therapy

that was designed for individuals that

have

complex mental health problems

and originally designed for individuals

that are

suicidal or self-harming

and who may meet criteria for a disorder

called borderline personality disorder

so i so at its simplest i would say it's

a form of cognitive behavioral therapy

that was designed for more complex

people or

presentations but then of course there's

a lot more

nuance uh beyond that yeah which we'll

we'll certainly get into um

maybe give people a bit of background on

what cognitive behavioral therapy is i

mean that term

i've heard a lot but truthfully i don't

know much about cbt outside of cbti

which is cognitive behavioral therapy

for insomnia

which we have referred

i would say over the past five or six

years probably a dozen of our patients

to cbti practitioners

and i think i can say without exception

it has always proved to be incredibly

valuable not just incrementally valuable

but incredibly valuable but that's

that's the very limited experience that

i have with with cbt is through that

that one narrow lens is there something

more broadly we can say about cbt that

then allows us to contrast it with dbt

yes so cpt it refers to maybe a class of

uh talk therapy and could often be used

to contrast uh with other kinds of talk

therapy but some of the distinguishing

features of cognitive behavioral therapy

is that it's present focused so focused

on what's happening for people

right now in terms of the problems

they're experiencing and less focused on

one's history

um one's childhood

uh less focused on the sorts of things

that have led to the person experiencing

the problems that they're experiencing

so it's present focused and it's as the

name implied it's focused on um working

with thoughts and behaviors that go

along with the problems that people

experience so in cbti for example it

would be you know what are the thoughts

that are contributing to your insomnia

uh and how do we work on modifying or

changing those thoughts that you're

having in order to increase the

likelihood that you fall asleep let's or

stay asleep

what are the behaviors that you do that

promote sleep what are the behaviors

that you do that get in the way of sleep

and how do we modify that so at its most

concrete level it really is working with

thoughts and behaviors that in the

present

that are contributing to your problems

right now so it's very much an active

problem-solving

approach

and i think what is um

with people who don't have a lot of

experience with therapy

or

receiving mental health treatment

they might have an idea

based on

the media or tv or movies that the best

therapy is one where you just go in and

talk about whatever's on your mind

and cbt and similarly dbt is much more

structured and and guided

than that and

the other the other distinguishing

feature i will say about cbt and dbt is

that

it's evidence-based meaning that we

construct treatments

in a way that we could measure

its effectiveness and if we find that

something is not effective for people

then it's not likely to stay in the

therapy that's that's our goal anyway is

to be as empirical in our and scientific

in our approach as possible

so how long has cbt been around as a

discipline

i would say it emerged you know probably

the figure that is associated with the

beginning of cbt is a man named aaron

beck

who

died last year i believe at the age of

100 and so he or something like that

number

um

i would say it was probably the 60s in

which he first started developing

his form of cognitive therapy he was

trained as a psychoanalyst

and was seeing

that it wasn't all that useful for a lot

of the patients that he was treating in

psychiatry and so he started developing

an approach that was much more about

changing the way people

thought

about themselves and others

so

let's talk about marsha

who is obviously a very marcia linhan

who's a you know

uh i i think it's safe to say really the

creator and founder of dbt is that a

fair statement

yes for sure um so tell me about her

journey

presumably

she had tried cbt

both as a patient and maybe even as a

therapist

before realizing that there was a way

that it could be improved upon for at

least a subset of patients and or a

subset of problems would that be kind of

a fair

statement yeah so the origin story of of

dbt was that originally marcia set out

to apply

what might be standard considered

standard cbt

to folks who are chronically suicidal

and um this was you know perhaps

beginning in the 70s uh she was

receiving advanced training at stony

brook in

new york

at that time stony brook was considered

one of the premier places to learn and

apply behavior therapy

and back in the days of the

70s uh 80s there was really the heyday

of behaviorism and the idea was

in some way in many ways oversimplified

but the idea was that we could treat any

mental health problem

with behavior therapy

in very few sessions um just by applying

these you know standard principles of

what we know about behavior change can

you by the way can you give me an

example of what that would be so

does that mean that if

if a person was clinically depressed and

came in

and they were suicidal what would the

cbt approach have been in the 70s or 80s

to

address that concern

well i might if i can come back to

depression and suicide in a minute but i

might start with anxiety disorders

because this is actually uh what um

behavior therapy and cbt was probably

most uh prolific about in those days

and the idea was that you could have

somebody who came into treatment with a

fear of something a phobia it could be

something like a fear of heights or a

fear of spiders or it could be a fear of

social situations

social anxiety and the behavior therapy

approach to this or the cognitive

behavioral therapy approach to this

would be

to teach people

competing thoughts so rather than

thinking

this

thing will kill me

um i can learn to have thoughts like

um

i can tolerate this

uh this might be difficult but i can i

can

handle it or even have thoughts like

this is not going to kill me um but

those thoughts were only one part of it

the other piece of it was the more

behavioral piece which is

uh exposure basically saying that how

you're going to get over your fear of

spiders is not to talk about it

every week for an hour with somebody but

it's actually going to be

coming into contact with spiders

repeatedly over and over again

so that you learn

that uh you can handle it uh but you

also learn that the feared outcome is

not going to occur

so so that was uh so

change your thoughts and get exposure

change your thoughts get exposure

exactly and the getting exposure is

changing your behavior because you want

to run away or avoid

and instead it's saying come into

contact with approach something that you

want to avoid

and so what they were finding in these

you know early days of applying cbt is

saying

uh you know people may have gone to

psychoanalyst uh psychoanalysis which

was the dominant paradigm of therapy in

those days and and by the way this is

almost

exclusively

a rich white person

issue when i'm talking about you know

who is receiving treatment for mental

health problems

that's what i'm talking about back in

those days um

largely

and so

people could go to a psychoanalysis

psychoanalyst and talk about their fears

for months and years and not necessarily

do better with them and so cbt comes

along and says actually

we could do this sometimes depending on

what the fear is in one session there

were people who would do like a

three-hour session to you know

quote-unquote cure somebody

of a phobia and and they were finding

that it that it worked and so then you

say okay how do we take those principles

to something like depression

uh and this is what aaron beck started

to do with cognitive therapy more was

noticing that people who have depression

tend to think in very particular ways um

they have

uh

negative um

interpretations

of

almost everything right and also about

themselves about their future

about others and so a cognitive

behavioral approach to depression would

be about working on changing those

thoughts to be more balanced and

evidence-based and then also the

behavior change that goes along with

depression is usually about getting

active

so when somebody is depressed

the the tendency is to retreat shut down

avoid

and

the behavioral treatments for depression

would be to get people activated uh and

to solve the problems that are causing

the depression

whether it's unhappiness with a job uh

unhappiness with a relationship and and

work on targeting

the problems that are causing depression

in a systematic way

how successful was it you mentioned

earlier that evidence is a very

important part of this

um

how were they able to tally the results

and determine if their intervention was

in fact better than the standard of care

at the time

right so uh

the history of psychotherapy trials is

largely

based on a paradigm known as randomized

clinical trials where

you would recruit individuals who meet a

certain inclusion criteria say somebody

meets the diagnosis for depression

and then you would randomize them to

either say receive you know 12 weeks of

cognitive behavioral therapy or receive

nothing

or receive a

treatment as usual or standard of care

and then evaluate outcomes over time and

with things like uh depression and

anxiety disorders there are these

standard measures that are you know

popular within our field

where we have developed benchmarks for

what uh we're trying to get to you know

what might be considered a success and i

would say that in general that the

trials for cbt

for things like depression and anxiety

are are overwhelmingly positive

meaning that most of the trials

especially in the early days when you

were comparing cbt to

nothing or you know treatment as usual

found very large effects uh for cbt

um in those settings now i think uh

where we see or where we'll come back to

marcia emerging is recognizing that of

course

uh

none of these treatments were 100

successful um for everybody and

more than that is that when you look at

these studies and you see

who were these studies done with the

inclusion criteria meaning

what allowed somebody to be in the study

were often quite narrow

for example with a depression study the

person might have to meet the criteria

for a diagnosis of depression but not

have

suicidal behavior

so people with suicidal behavior

may be excluded from a lot of those

studies which

makes sense from a research point of

view in some contexts but in other

contexts does it make sense because of

course we know that a lot of people who

experience depression

um are also suicidal so if you're

removing suicidal people are not

allowing suicidal people to be part of

this research

then we don't know

ultimately if the treatments work for

those populations

so when did i mean marcia as a young

girl i think was diagnosed with

schizophrenia is that correct and was

treated with electro convulsive therapy

and all sorts of things that are still

used today but probably not as

frequently and probably with a bit more

uh particular

attention to the use case

probably used more liberally than i'm

guessing

so marcia was a teenager

i believe at the time that she was

receiving a lot of treatment and

this was in the late 60s if i'm no wait

if i'm remembering correctly what uh

when she was born now that i'm thinking

about it but uh it was before

cbt was really in the picture

and she was

sent away uh hospitalized for

being suicidal and

chronically self-injuring doing a number

of things to cause physical harm to

herself as a way of

relieving

emotional intensity and overwhelming

emotions and so at the time there was

not

a lot of treatment options that were

available and the medical model was to

treat with really

strong

meds uh you know antipsychotic meds at

the time

or to use something like

electroconvulsive therapy

and so those were the treatments that

she was exposed to from

a very young age in addition to therapy

but the types of therapy that she was

receiving at that time uh were unlikely

to be um

you know anything like

the cognitive behavioral treatment we

know today

so how did she find her way from

being almost institutionalized to

eventually

you know getting an education and

herself becoming a therapist what was

that journey that went from that

teenage girl to

kind of the the person who created dbt

yeah so she has uh written about this in

a memoir as well as uh described it in a

piece in which she uh in the new york

times which was a piece where she kind

of came out to the world as having

been someone who experienced her own

struggles uh significant struggles with

mental health and i say that as a

preface because uh for

that article in the new york times came

out i believe in 2010 2011 so

for most of her career she was not

forthcoming about this

her own personal struggles she would

tell

people that were close to her knew her

students i was one of them

knew about this experience but she

wasn't public about it

and

she would long say that the reason for

that is because she wanted dbt to be

judged on its merit

empirically she did not want um

uh

dbt to be judged on her personal story

alone she she wanted this to be a

scientific treatment that that lives and

dies by its outcome she would say

so

so um

so when she would talk about how dbt

developed

um

to the public is she would talk about it

in um leaving out this earlier part

of her own history so the earlier part

of her own history that she describes is

that she she had a spiritual moment um

when she was in

one of these institutions

and the spiritual moment was

that she

describes

experiencing god in a very dark moment

of her own life and in that moment she

realized that

she could she felt the love of god and

felt that she could

serve

this purpose in life which is to get out

of hell

her own experience and then to work uh

her entire life to get other people out

of hell

and that was how she

took this spiritual experience

and

developed her

life's work based on that

now another reason why she did shireen

at that time

i would say

um as best i remember in her early

late teens or early 20s

kind of profound to be

to follow through on something that you

know you could argue

well god you were still so young when

that was happening and

and was she at some point here diagnosed

as having a borderline personality

disorder as well or is that something

that is more

retrospective where it's sort of like

looking back she was probably

misdiagnosed as having schizophrenia i

mean what what was the state of

understanding of her her actual

condition

uh

so i believe that she was probably

you still see this today but when people

are unclear about how to explain

someone's problems they get given almost

every diagnosis in the book

and now this would have been before the

criteria that we now know is borderline

personality disorder being defined and

the way it uh

is most well known

um

would have started in the third edition

of the dsm which uh came out in about

1980 so the criteria that we have now to

define borderline personality disorder

was not the same as when she was

receiving treatment so i believe that

she had a number of diagnoses attributed

to her

um it's i can't remember it's quite

possible that borderline personality

disorder was one of them

um because of course that's also the

diagnosis that they give people when

they don't know how to treat them

uh and so it wouldn't surprise me and

what what are the criteria tell tell

folks what borderline personality

disorder is today what do we what do we

know today

yeah so borderline personality disorder

is considered a complex mental health

disorder

that

is

defined as

meeting

there are nine criteria of borderline

personality disorder as defined by the

dsm and in order to meet criteria or to

have the condition

you have to endorse five of the nine

which actually means that ultimately

it's a really heterogeneous disorder

because there's all these different

combinations and different ways in which

one can meet criteria

uh what one of the things that marcia

did um

was to

restructure the different criteria

borderline personality disorder in a way

that that perhaps is more understandable

and also makes more cohesive sense

and to say that it's a disorder of

dysregulation across a number of

different domains

so the core domain of dysregulation that

we see in borderline personality

disorder is what we refer to as emotion

dysregulation

and this is largely defined by people's

experience of emotions as feeling

like um

they have very intense emotions

they don't feel like they can control

their emotions very well

their emotions change very rapidly

so that's referred to as affective

ability that the emotions will go from

intense sadness to intense shame to fear

to joy you know very quickly and

seemingly without a lot of uh reason

so emotion dysregulation

is part uh and considered core to the

disorder of borderline personality

disorder and then these other domains of

dysregulation

stem from

emotion dysregulation and include

behavior dysregulation so not having

control over or feeling like you don't

have control over your behaviors

this is associated with a lot of

impulsivity

and behaviors that go along with

impulsivity so substance use

reckless spending

impulsive sexual behavior

uh

impulsive driving you know behaviors

that are experienced as impulsive and

potentially could cause problems for the

person

impulsive eating uh is another domain i

mean it sounds like there's quite an

overlap at least in some of those with

bipolar disorder right bipolar one where

you could sort of see i don't know about

the

effective lability but

certainly the mania side of it sounds

like it might be consistent with some of

that dysregulation i'm guessing that's

what makes psychiatry

so difficult is you don't have

biomarkers you don't have imaging scans

that give you diagnoses right

right uh we don't and so there is you're

right a lot of overlap and actually

probably the ones the overlap

that is more consistent or difficult to

discriminate is bipolar ii

because bipolar one is associated with

the depression longer

longer lengths of either a pure manic

state or a pure depressed state

bipolar ii

might have manic states but it is

shorter in duration or might not be

you know super manic right as high and

so that's that's often really hard to

discriminate from

um

somebody

uh who has borderline personality

disorder and generally what we're

talking about with with

bpd as opposed to bipolar is that we

actually see the mood

changes happening more frequently

uh within bpd

than with um bipolar ii but i i'm

probably oversimplifying but that's what

i would be looking for if i was trying

to assess the difference

between the two

a person with uh bpd

um

what are what are the challenges that

they face in the in the world right if

this is a let's just assume this is a

person of

totally normal intelligence and other

all all physical capabilities are fine

and this is sort of the one issue

this one psychological issue

how does it manifest itself for that

person when they're in school when

they're in college if they get married

if they have kids like

help help us understand

how this condition makes life more

difficult for the individual and and

those around them

yes so one thing i'll say is that you

rarely will see this condition in

isolation of anything else and again

this speaks to one of the complexities

of trying to study psychiatry that i

think

on average people who who meet criteria

for bpd have three to four other

mental health problems at the same time

so they'll also meet criteria for

depression or an anxiety disorder or a

substance use disorder or

an eating disorder

and those things aren't stemming from

the bpd these things are

we believe independently there as well

well

i think it depends on who you ask

because i would say as somebody who is

trained mostly behaviorally i would say

the diagnosis matters less than how we

conceptualize these problems and to that

point i would agree with you we could

say emotion dysregulation is is central

to all of those things but the

diagnostic system as we currently have

it

does not allow for that so they would

say you know if somebody meets criteria

for these other disorders they also have

these other disorders right

so how somebody with borderline

personality disorder you know lives

their lives i would say

um it's complicated because on the one

on uh and it ranges on one end of the

continuum you know we see people who

have

uh severe problems associated with bpd

such that they

they struggle to hold on to a job

um so they don't work and they're on

disability or receiving social security

they um

they can't maintain relationships

so they're they're very isolated

and why is that why why are

relationships blowing up and why are

they not able to hold down a job what's

the fundamental issue or fundamental

issues

that are impairing them

from a dbt perspective we would say that

it all

comes back to difficulty

regulating emotions

so that if i experience intense

emotions that i

feel like i can't control

when i get angry i lash out

when i get scared i

run away or avoid or i have

a motion just one of the criteria that

goes along with bpd that you could see

as tied with emotion dysregulation

problems is

what's referred to as fears of

abandonment so a person with bpd often

will

have a lot of fear

that a

person that they love or are close to

will leave them

and if i am in a relationship where i am

afraid that the other person is going to

leave me

all the time

that may cause me to behave in ways

that are frantic

chaotic and actually um paradoxically

have the effect of causing the other

person to be more likely to leave right

texting the person calling the person

relentlessly

um if if a person doesn't come home or

call at the time that they say they will

um

you know having the experience of

feeling like i'm losing it because i

don't know where that person is or

perhaps they've they've left me as a

result if i have bpd i experience

intense fear

intense shame intense sadness and now i

don't know what to do

with this intense behavior and i may

self-injure

as a way of relieving

that emotional intensity or

i may

threaten suicide as a way of getting the

person to come back

to me and maybe i'm doing this without

even having awareness that that's the

effect of my behavior i just know that

in this moment i don't know what to do i

feel entirely out of control and i need

to do something to to fix it in this

moment

what is the um mortality of bpd i i i

was very surprised to learn recently

that um anorexia nervosa has probably

the highest mortality of any psychiatric

condition i would have guessed

depression presumably um but where does

where does bpd stand in terms of

mortality

either through

self-harm and neglect potentially or

obviously suicide

i sometimes get into the weeds a little

bit about this and when as a as an

academic and psychologist what i

find

and someone who studies suicide i review

a lot of manuscripts and and grant

proposals and i am always um

uh

saddened and amused when i see people

you know write about a disorder and say

this disorder has one of the highest

rates of suicide because if you look at

it it seems like every disorder has one

of the highest rates of suicide and i

think it's because we don't know how to

study this very well honestly we we

don't know how to

um

how to determine of the people who die

by suicide

what are the

mental health conditions that they had

and what is the relative risk according

to these different disorders yeah well

especially when you overlap because as

you said earlier if a person

with bpd also suffers significant

depression if they commit suicide are we

attributing that to depression or to

yeah so so no i think my question more

broadly is knowing that one could never

tease that out

how risky is it for an individual

understanding all of the comorbidities

that that tend to cluster with it

i will say it's very high

and one way in which i can answer this

is that one another criteria for for bpd

is

uh repeated or chronic self-injury or

suicide attempts

and

upwards more than 75

of people and in some studies

90 to 95 percent of people who meet

criteria for borderline personality

disorder engage in self-injury

um or have made more than one suicide

attempt in their lives

and this tells us a couple of things um

one is that there

that that on its own is considered a

very high risk behavior because people

who engage in self-injury even if they

don't intend to die

there could be accidental death as a

result of self-injury

what are some examples i mean people

probably think of the most common

examples of people cutting themselves or

burning themselves

what are some other examples of

self-injurious behavior that people

engage in

um head banging uh

or

um

punching or hitting oneself

there are

multiple forms of of cutting

that

include you know different objects to

cut but could also be people

um

really intensely scratching themselves

to the point where they uh draw blood

there's overdosing is considered a form

of um self-injury

uh

especially if it's um or you know you

have to determine is this with intent to

die or not but but there are people who

overdose without intent to die

um as a way of hurting themselves

there's also um

you know more rare but other forms of

self-injury may involve

ingesting toxic

substances uh

et cetera so um

this has also i think evolved over time

or we didn't know how to study it very

well over the years because even in my

career i feel like 20 years ago when we

were talking about self-injury we were

talking much more about things like

cutting or burning and i feel like as

there have been more people interested

in studying self-injury we're also

finding out about other ways in which

people

cause harm to themselves and then

there's all sorts of debates about

whether this you know

is considered self-injury or not because

some people might say

i

i have binge eating or i overeat and i

and i do that intentionally even though

i know it's causing harm to myself

whether we classify that

diagnostically as self-harm or not um is

one question but whether a person

considers themselves actively doing harm

to themselves that's that's another

question what's the male female split in

in bpd yeah so that's another thing

that's changed over time it was long

thought to be a female disorder

and

um

and there's all sorts of reasons for

that a lot of them are sexist

now we

see

more studies that indicate that there

are roughly equivalent rates among men

and women

however

there's still a bias a diagnostic bias

for

tending to diagnose women more often as

bpd intending not to diagnose men

with bpd so does that mean

under-diagnosing men over-diagnosing

women potentially

i think so i think the under diagnosing

of men

is

has been shown in a number of studies

and it appears that men have to be more

severe

in order to receive the diagnosis

than

than women whether women are over

diagnosed i'm not sure but i i think

it's very rare that you would see

a psychiatrist or

a medical professional do a diagnostic

assessment

i think it's much more likely that they

base that diagnosis on

is this person difficult in some way

so when you look at the twin concordant

studies of things ranging from autism to

depression

you see a very strong genetic component

to these things do you have a sense of

how strong the genetic link is for bpd

presumably based on these identical twin

discordant studies identical twins

raised separately and looking at the

prevalence um

how much of this is genetic

and then how much of this is

environmental where

life events

trigger a susceptible individual to

manifest the traits

so i don't know the the data off the top

of my head about the twin concordance

but i would say there's a general

understanding that there there is

of course a genetic component to this

disorder

and i would say that the the dbt

framework

is one that has a model for explaining

how bpd develops which we can probably

get into but that speaks to

the

the fact that there is both a genetic

and an environmental component um to the

development of the disorder

so let's go back to marcia in her

journey so

she has this

you know literally come to jesus right

so she has this kind of epiphany in her

late teens or early 20s

which it sounds like

you know puts her on a different path

potentially saves her life

it's still a long way from there to

where we are today so walk us through

that journey

right so this is where it picks up in

terms of the story that um

is part of the

the development of dbt story

so

um

now leaving out her own personal history

you know marcia went on to get a degree

in i mean i should also point out that i

think one of the factors that led to

marcia being able to do this is that i

think she's hands down a genius

and so that was probably um

uh despite her really difficult um

experiences

she had this

amazing capacity for you know thought

that helped her

i'm sure in numerous ways including

developing this treatment

but so she went on to get a degree in in

social psychology a social psychology

phd

which is a little known fact about her

that she's not a clin she doesn't have a

degree in clinical psychology but she

got her social psychology degree but

then decided that she wanted to get

clinical training and that's what led

her to this um training experience at

stony brook which is where they were um

doing a lot of work

on theory and treatment related to

cognitive behavioral treatments for a

range of disorders

and at that time nobody was studying

cognitive behavioral treatment for

suicidal populations

and so marcia decided

i want to take what we know about cbt

that seems to be hugely effective for

all these disorders and i want to take

all that we know about cbt and just plop

it into

treating

chronically suicidal individuals the way

she reports it is saying she wasn't

interested at that time in diagnosis she

just wanted to work with people who

chronically experienced urges to die and

so that's what she attempted to do and

by her accounts

um this quickly blew up and just because

just for timing this is kind of i'm

guessing this is now the early 80s

yes okay late 70s

early 80s when she did her fellowship

there and do we have a sense of how

she is treating herself at this point in

other words how is she regulating her

own emotions are the tools of cbt

things that she is finding helpful for

her own self-care

this is a great question and i'm not

sure i know what the answer is and

what's interesting is that it's it's um

i think that what marcia did was she

took a lot of her own experiences and

then she was able to translate that

into cognitive behavioral terms whether

she and and which led to the development

of a lot of the skills in dbt that she

developed for people

whether she was

um

thinking at the time about applying cbt

to herself i don't know but i think that

that's uh what she ended up doing yeah

by developing nature so she sort of

became the index case right you know she

was sort of

not necessarily thinking at th this way

but she was working out the tools of how

do you transition

you know i sort of liken that to what

bruce lee did i don't know how familiar

with bruce lee but you know um

you know

most people sort of know him as you know

kind of a movie star in martial arts but

but he was far more relevant in creating

a system of martial arts called jeet

kune do

took from over 30 different other styles

of martial arts and and

in his words

took what was useful and discarded what

was useless

and

sort of created a new system with a very

particular goal by the way so he had a

very clear objective in what jeet kune

do was to be about

um

and it in some ways it's almost like

that's what marsha was doing on herself

right

yes on herself and also in her

treatment development work which is you

know a very iterative process like let

me try this does this work i'll keep it

does it not work i'll throw it out

if it works

what is it how do i define it

how do i write about it in a way that

other people can do it

and

and

you know put it all together in a

package again i think this speaks to how

brilliant i think she is that that she

could do it but it it it does align with

what you're describing which is

really

um

and what's i think really exciting about

treatment development work is this whole

process of of

of figuring it out as you go and then

trying to replicate it um and really

using

the the client's experience to say is is

this having the intended effect

so i interrupted you but let's go back

to marcia stoney brook and

finding out that

cbt in its current form is not helping

suicidal patients at least not to a

level that she's feeling is successful

right

right so what she

uh again this is second hand so i just

tell the story as though i'm her but

what she would uh report is okay i go

into my session with somebody and i

asked them about what are all the

problems that you're experiencing that

it's causing you to feel suicidal and

the person would say

uh i hate my job you know i hate my

relationships uh i i don't have any

pleasure in my life whatever those

things are

and marcia with the cbt lens would say

no problem uh we can figure this all out

we'll just you know take all of your

problems we'll put them on the list

we'll systematically go through each of

your problem one by one which we'll

solve and uh we'll we'll figure this out

in no time

and the way she reports it is that she

she did that feeling all the hope in the

world and the reaction that she got was

totally unexpected which is people

saying

you have no idea

you have no idea how bad my problems are

if you thought that these are things

that are easy to solve you are

sorely misunderstanding the depths of my

problem you clearly don't understand

anything about me or my situation if you

think that these are something that

things that could be easily solved

and more more than that if these were

easily solved i would have solved them a

long time ago you have no idea how much

i'm suffering

right you don't get it

so this iterative process was like okay

this blew up right clearly uh

this isn't working the way i intended

and so the next uh

piece of her story is she would say okay

that's not working i need to figure out

what's going to work

and she said she took kind of the other

perspective and she said okay what

they're telling me is that i don't

understand the depths of their problems

and maybe that's true and so what i need

to do now

is

is tell them and work with them to

completely understand and so she would

go into her sessions with again you know

people who are chronically suicidal

and say

you're right

your problems are too difficult you've

had long-standing

um experiences

with trauma you've been treated terribly

your whole life

uh you have a number of obstacles that

may prevent you from getting the job

that you want or the relationship that

you want

and

perhaps

what we need to do is work on accepting

your life you know as it is

um and and finding joy in that but but

accepting you know the life as you as

you have it and let go of

you know trying to solve all these

problems

and so that was her next

step so so this is the this is the

epiphany that of course anyone who's

done dvt knows is radical acceptance

well it wasn't quite labeled that yet no

no yeah but was this kind of the

precursor of what we would now describe

as is that

what i would say yes i think it could be

the precursor but it was missing

something because what she would say is

like this is the acceptance piece

but when she tried it thinking oh this

is what people want you know they're

saying i can't solve their problems and

so clearly if i communicate that i

understand

how difficult things are and we can work

on accepting it

uh the reaction she got then was what

there's no hope

how can you say that i should just

accept this my life is miserable as it

currently is you know if i accept this

there's no hope i should just die

uh you again you don't possibly

understand you know everything and this

was the um you know dbt stands for

dialectical behavior therapy we can talk

about dialectics um but this is what

turned into

the the idea of this primary dialectic

in this treatment which is the dialectic

between change and acceptance

and and figuring out how how do i as a

as a therapist as a treatment provider

straddle this line synthesize this

because both of these are important we

need to work on solving the problems in

your life that are causing you such

distress and misery and we also need to

work on accepting your life as it is

and accepting the things that that we

can't change um about our lives but how

do we do that in a way that is palatable

to the person on the on the other end

and in a way that says uh

that conveys hope um that things could

change and so it's about synthesizing

those two elements and i think it's the

it's a synthesis of those elements that

lead to things like radical acceptance

and

other uh components of the treatment

so this is probably a great time to

double click on what dialectical means

because it is

i don't know i i'm not sure if it's

innate to us right i think it requires

some practice

yeah i was listening to some interview

the other day where somebody just simply

said

humans don't like contradiction

and i think that that's true we don't

like contradiction and so dialectics is

really the um at least i'm by the way

i'm no expert in dialectical philosophy

as you know as marx um

initially wrote about it i'm i'm more a

student of dialectics as it informs you

know my life and my practice but

uh dialectics is this understanding that

there is contradiction and opposition

and tension

in

everything

uh and

therefore

we can't avoid it

um and the more we try to avoid conflict

and tension um

the more likely it is that we're going

to see conflict and tension

and so dialectics is at least again in

the practice of dbt

is the practice of recognizing

tensions

as they exist polarization as it comes

up and then striving to find

what is valid about both sides

or both sides of the tension and seeking

to find a synthesis

some new argument or new statement that

recognizes um and adopts the validity in

the two opposing sides

this might be a reasonable time to jump

forward and then i want to come back

because i love this sort of story but

if you've if a person listening to this

or watching this has ever kind of gone

through dbt then they're familiar with

the workbook right you're doing this in

a very structured way and

one of the first images in the workbook

is the two intersecting circles of wise

mind and emotional mind

do you emotional mind and reasonable

sorry reasonable mind yeah why is mine

being the intersection yeah so um

maybe use you want can we use that as an

example of dialectical synthesis where

you have those two

minds uh intersecting and then that that

union or intersection of them being the

wise mind and how do we find those but

but again contrasting it with with uh

sort of emotional and reasonable mind

yes so i think

you um that's exactly right that that is

an illustration a key illustration of

dialectics at play is this is this

notion of wise mind and

the way we and wise mind being a skill

in the workbook that we teach people as

something that we

um are striving to

uh

to access wise mind more often in our

lives and that that accessing wise mind

involves

synthesizing

these these two tensions potentially or

polarizations known as emotion mind and

reasonable mind

so

we

emotion mind is the idea that

a state in which we are completely

controlled by our emotions

uh so when we're angry it could be

lashing out at somebody it could be

engaging in physical violence it could

be threatening physical violence it

could be

slamming doors uh it could be quitting

things you know all the things that we

might do when we're when we're being

controlled by the anger we're

experiencing

reasonable mind on the other hand is

when we're controlled kind of by facts

and logic

and emotions aren't really um

uh we're not aware of or experiencing

any strong emotion and you could you

could imagine or you can envision the

tension that exists between these two

if you've ever been

in a motion mind having an argument with

somebody in reasonable mind uh or vice

versa because um that happens a lot i

think it has happened in my marriage it

probably happens a lot uh across many

people's marriages where one person is

in a motion mind the other person is in

reasonable mind and that's a recipe for

uh you know a really strong conflict

so wise mind is saying

okay what can i um

what's valid about the emotion that i'm

experiencing here uh what's valid about

reasonable mind that i'm experiencing

here and once a synthesis so a silly

story that we might tell to illustrate a

wise mind or emotion mind is

you're walking down the street and you

pass by a pet store and in the window

are

a dozen

puppies

or if you're a cat person imagine a

dozen kittens okay

uh emotion mind

takes over

and says get them all i want all the

puppies

every single one of them because this

one is cute for this reason this one is

cute for this other reason oh my god

they would be so happy together and i

would be so happy if i had all these

puppies in my life i want them so

emotion mine says get all the puppies

reasonable mind

says

oh my gosh dogs are so much work

you have to walk them

three times a day they're expensive you

have to get all this equipment uh you

have to

get a veterinarian you have to

restructure your time so that you spend

more time with the dogs or not you have

to you know reimagine your whole life

around that so reasonable mind might say

no puppies uh puppies are never for you

right

so what does wise mind say well what's

great about even teaching this as a as

an idea is that wise mind is not um

or and a synthesis a dialectical

synthesis is not a compromise it's not a

halfway point because if i were to say

that then wise mine would say get six of

the puppies if there are 12 right uh and

that makes no sense

as a compromise

or as a synthesis because it's not

seeing the validity in both sides so

what would wise mind be that would vary

depending on the person because for some

people a wise mind decision would be

to bring home a puppy

for other people a wise mind decision

would be to say now is not the right

time for me to have a puppy but i am

going to do x y and z

in order to increase the likelihood that

i can have a puppy in the future

wise mine might be i have the perfect

scenario now i can bring home two

puppies and we will live happily ever

after so it's going to to vary but the

idea of finding this synthesis is about

um

seeing what's valid and true

about both ends of the

or both of the sides and then trying to

figure out um what a synthesis could be

does that make sense it does it really

does of course and um

i think one of the things i'm struck by

when i look at the

the notebook the workbook that we use in

dbt is how much is in it

and

to think that this is sort of the work

of largely one individual and obviously

it's been iterated on but

it's really kind of remarkable so can we

kind of go back to the story of

some of the earliest insights she had

treating

some of the most in need patients

and how

she basically then realized she couldn't

do what she was doing under the umbrella

of cbt

and needed to make this change from the

cognitive to the dialectical and create

another form of behavioral therapy which

again is

it's really a it's really a kind of

remarkable um thing to to realize given

how relatively recent this is i mean

this is something that's happened in the

last 30 or 40 years

agreed yeah

so i think you know getting back to

where she

was in terms of realizing that you know

if i push for change

too hard disaster happens if i push for

acceptance too hard disaster happens

what can i do to you know find

um the middle how do i balance these two

things and

again part of the the lore of the story

of dbt was that she was um writing about

this idea of balancing change and

acceptance and these were the days where

she would you know write up notes either

handwritten or on a typewriter and hand

them over to a secretary who would you

know type them up or revise them

and uh her story is that the person her

her assistant that was working on typing

this all up

came to her one day and said my husband

is a graduate student in philosophy

and

uh

we were looking at this and we think

that what you're describing actually is

something that he he studies uh and is

called dialectics so according to marsha

she didn't know anything about

dialectical philosophy

um as she was

iterating this treatment and this was

one of those happenstance moments that

um that came to her and then of course

she sought out readings

uh descriptions of dialectical

philosophy and saw yes that is exactly

what she's thinking and that dialectical

philosophy

informs

a lot of science uh and scientific

thought and so um

actually worked well

within

the the paradigm of you know the

development of of cognitive behavioral

treatments

so

so that's where you know dbt started to

take form

however if if you're familiar with her

books you know that her original

treatment manual that was published in

1993

uh including the and and also the

original skills workbook that was

published in 1993 says on the cover

cognitive behavioral therapy for i

wasn't aware of body disorder

the the newer edition says dialectical

because she was told at the time by the

publishers that nobody will know what

this means and nobody will want it

uh and i think that may be true it's

it's possible that

if it was called dialectical behavior

therapy on the cover of the book back

then it would not have

actually been as popular as it is now

now of course we can put dialectical

behavior therapy on the cover of any

book and

um and people will see the value in it

but i don't think that was true then

when did she develop kind of her own

sort of interest in zen philosophy

and the practice of mindfulness which

also is a very important

muscle that one kind of develops as they

move along their dbt journey was this

something that had been more

long-standing with her

so i think that this was

all happening

around the same time

that she was

her own interest in you know marcia grew

up

in a catholic family identified as a

very uh religious person identified as

saying that at one point she thought she

was um going to become a nun

uh and so this was a large part of her

upbringing

when and also was part of that spiritual

experience that she had personally but i

think she also

uh realized that and another reason by

the way that she didn't want to come

public with her story early on is that

she didn't want

the lesson to be

oh if you want to get better you also

have to have a spiritual

experience

instead what she wanted to figure out

was how do i

um

how do i operationalize

for lack of a better word this spiritual

experience so that other people

could experience it as well and so i

think

that was going on in her mind at the

same time that she was um interested in

her own spiritual development and um and

learned more about zen and became a

student of

zen buddhism and saw that they they all

connected and came together because

ultimately how she translated that

personal experience

um

is into this idea that you mentioned

earlier of radical acceptance

can you radically accept

this moment this situation

yourself exactly as it is and if you can

experience that radical and complete and

total acceptance

you can experience

joy

you can crack open the moment of joy she

would say yeah i mean

there are some things where you know

shireen that's

i get it right like you're stuck in

traffic right so you're you're you're

you're supposed to be going somewhere

and let's pretend it's some place that

matters right it's not just like a

dinner reservation let's say it's your

kid's sporting event or you going to the

airport and it's a flight and you if you

miss it it's going to really wreck

things up and

there's nothing you can do about it

you're stuck in traffic there's an

accident a mile ahead and that this is

the way it's going to be

walk me through

what you would say

you know your

your your patient now is in the car and

you're sitting with them in the car

and they're understandably getting very

flustered at the situation

walk me through

radical acceptance in that situation how

are you helping that person

go through the you know can you fix this

problem are you accepting this problem

can you change like going through all of

those layers

for that specific type of problem yes

and i've been in that problem for myself

so i understand yeah so you know

um

what i would say as a precursor is that

when we're experiencing suffering

however you define that suffering

if you were to look at it more deeply

you would say

the vast majority of the time that we're

experiencing suffering

it's because we're thinking about

something that has already happened

ruminating

wishing it hadn't happened

mulling something over whatever it might

be or you're thinking about something

that may happen

in the future

and that actually if you just experience

this one moment

uh

and let go of the past and the future

that alone might reduce your

suffering a ton but we could say you

might experience pain in this moment

because this moment might be painful but

we're not adding on we're not adding on

all of these things that actually

increase our suffering

so in this moment when you are

stuck in traffic

you can't undo

the decisions

that you made

that got you to this point right because

of course we're saying things like oh if

only i had taken this other road or if

only i had left 15 minutes early or we

think all these stupid people on the

road if only they had done something

different

right so that's those are all

fantasy thoughts because they're all

not reality of this moment

so i would say how do we reduce our

suffering in this moment

is to say i can't change any of that

for today in this moment this is what it

is

um and

what happens you'll see actually i'm

holding my palms up right now as i'm

talking because i associate holding my

palms up with this idea of

willingly accepting this moment which is

uh

this is the moment that i'm in yeah it's

sort of a surrender posture

yeah

yeah in a way it's the surrendering

willing this is the moment i'm in and

what happens if i just

just as though it's easy but what

happens if i accept that

right now there is nothing i can do

to change this

right

now i think the other piece to this is

and this is why it's not just about

acceptance because i would say

if this is something that happens a lot

right if you often find yourself in

situations whether it's traffic or

something running late or something like

that

then we absolutely want to figure out

how to prevent this from happening as

much

in the future

but in this moment when you're there you

can't do that

so in other words in the moment of

crisis you don't really want to be

problem-solving around

how can i avoid this the next time

how do i avoid this crisis again in the

future when i'm at a 100 or a 90 of

distress i'm not going to be able to

effectively do that

now obviously so much of what you're

saying

sounds very familiar to anybody who has

practiced

mindfulness or vipassana or one of its

derivatives in forms of meditation

um

we've had a couple of podcasts that have

have sort of gone into that and

you know when

the goal of the practice is to help you

identify

thoughts

and to separate you from these thoughts

and so in this individual

i mean

there's probably nothing as you say in

this exact moment that is particularly

unbearable

but the thoughts are unbearable if

you're if you let them go right

which is i'm gonna get to the airport

i'm gonna miss my flight then i'm gonna

have to wait for another flight and i'm

probably gonna miss that too or they're

not gonna be a good seat or whatever and

then i'm gonna not get to where i'm

going and maybe the whole trip's gonna

do that and and so

what is what do you say to the person

who says okay shireen i understand that

those thoughts

which are all future

are

not happening to me now and i can just

sit here right now in this car and

frankly i could turn on music and enjoy

the music for the moment

but that doesn't change the fact that

that's going to happen it doesn't change

the fact that in an hour i am going to

get to the airport i am going to have

missed my flight

what do you say to the person when they

they acknowledge that i could probably

take myself down from 100 to 50 by being

present in the moment

but will i get back to 100 when i get to

the airport when i realize that i now

have to deal with this mess

possibly but that's a new moment now now

you're in a new moment and a new

situation so part of it depends on well

what's your

what's your goal

uh so when you're experiencing distress

in that moment of being stuck in traffic

and not having any control about that

what's your goal

if it's to get to the airport

in two minutes

sorry that's not a realistic goal we're

gonna have to let that one go if it's to

problem solve what will happen when you

get to the airport is there something

that you can do while you're in the car

you know possibly but if your goal is to

how do i make this moment more bearable

because i can't undo anything

then i think we have some other options

available to us which could be

distracting you know doing something

like

music or

or

some other forms of distraction that you

could safely do in the context of your

car

okay so now let's look at kind of the

other end of the spectrum where

i think it becomes even harder to do

this so i'll think of two examples i

think of an individual who receives a

terminal diagnosis

so they're diagnosed with a cancer for

example that um

and let's let's make this even more

tragic right i think anybody dying of

cancer is tragic but now it's someone

your age or my age who's you know dying

decades too soon um but they're

basically

told and and it's accurate that look in

six months you're not going to be alive

um

so in that sense they're they're you

know they're they're mourning the loss

of their life and who they're going to

be away from

and then there's another example which

is very fresh in my mind right now

because

um you know my very close friend and my

wife's uh daughter drowned um a year ago

and and

because we're coming up to the one year

anniversary of that it's

it's all you know she's reliving a lot

of this

so

you know

it's hard for me to imagine what she's

going through and what her husband is

going through

but they can't there's no there's

there's nothing that will undo that

there so

so

maybe use those two examples as two of

the the most difficult examples of how

can radical acceptance

allow

the hey this this person who's gonna die

far too soon

to come to grips with that and maybe

have a chance at

having the best six months

that they can have

versus not you know you know and then

perhaps even more tragically the you

know a parent losing a child is you

would sort of hold that up as about as

tragic as anything can go

where nothing is ever going to bring

that child back

um and yes cognitively you can say look

you still have other children and you

have to be a great parent for them you

can't allow yourself to you know you can

go through all of that stuff but

like i don't know how i would cope with

that i don't think i could i'm not sure

so yeah now let's go from the sort of

banal of traffic to

the the really heavy stuff of life

yeah

easy right

so

uh i mean one

i've thought about both of these things

um

a lot or both of these circumstances a

lot and i think

one of the

misunderstandings about acceptance

somehow this idea that

if you accept something you don't

experience pain

and so i want to differentiate that uh

life is full of pain no matter how

zen and mindful you are you're going to

experience uh pain and a lot of pain and

we're not trying to eradicate pain

because actually

without pain um and i don't mean you

know physical pain i mean emotional pain

but it could be both but without that

we would have other problems right if we

did not experience

um

pain as you hear about your friend's

daughter

that would be a problem for you in a

different way

so

we need to understand that that pain is

going to be a part of our lives and

actually we cause a lot of problems for

ourselves when we try to escape the

experience of pain

so that's one thing about um reality

radical acceptance that i want to talk

about but the other is when when you ask

questions like that like how can we ask

somebody to radically accept this

i would answer in part by saying what's

the alternative

the alternative

is refusing to accept how do how does

that work

how how do you do that um

how and how long can you sustain that

for so i would actually argue that the

refusal to accept

or the putting your head in the sand

or the denying reality actually ends up

taking a lot more

mental

resource and

ultimately causing more problems for you

in the long run

and

that said from a dbt perspective when we

when we talk about practicing the skill

of radical acceptance we have another

expression called turning the mind

which is referring to the fact that

practicing radical acceptance

involves a very active

process

of continuously turning your mind

towards acceptance the the metaphor is

that you're at a fork in the road and

one road is acceptance and another road

is is refusal to accept you're gonna

come across the fork in the road

possibly multiple times a minute

and what does it look like for you to

say i'm going to actively and willingly

choose the road of radical acceptance

how can i

turn my mind my body my soul towards

acceptance and for me a lot of it is

actually asking myself that question of

what's the alternative

what other choices do i have

and recognizing that more suffering

comes from refusing to accept um more

often

the fact that it's referred to as

radical acceptance versus acceptance i i

think kind of highlights that that it

it's not easy it's not it's not a

decision it's not like you would sit