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

Aug 22, 2022 2h 16m 41 insights
<p><a href="https://peterattiamd.com/shireenrizvi/?utm_source=podcast-feed&amp;utm_medium=referral&amp;utm_campaign=220822-pod-shireenrizvi&amp;utm_content=220822-pod-shireenrizvi-podfeed"> View the Show Notes Page for This Episode</a></p> <p><a href="https://peterattiamd.com/subscribe/?utm_source=podcast-feed&amp;utm_medium=referral&amp;utm_campaign=220822-pod-shireenrizvi&amp;utm_content=220822-pod-shireenrizvi-podfeed"> Become a Member to Receive Exclusive Content</a></p> <p><a href="https://peterattiamd.com/newsletter/?utm_source=podcast-feed&amp;utm_medium=referral&amp;utm_campaign=220822-pod-shireenrizvi&amp;utm_content=220822-pod-shireenrizvi-podfeed"> Sign Up to Receive Peter's Weekly Newsletter</a></p> <p>Shireen Rizvi is a Professor of Clinical Psychology and Psychiatry at Rutgers University, where she is also the Director of the Dialectical Behavior Therapy Clinic. This episode focuses specifically on dialectical behavior therapy (DBT), a skills-based technique which was originally developed to treat borderline personality disorder (BPD) and has since been adapted to treat depression and other mental health conditions, as well as to help people who have difficulty with emotional regulation and self-destructive behaviors. Shireen explains the origins of DBT and how its creator, Dr. Marsha Linehan, came to find a need for something beyond cognitive behavioral therapy (CBT) when attempting to treat patients with suicidal behavior. From there, Shireen dives into how DBT works to resolve the apparent contradiction between self-acceptance and change to bring about positive changes in emotional regulation, interpersonal effectiveness, mindfulness, distress tolerance, and more. She also provides examples for how one can apply specific skills taught with DBT such as accessing the "wise mind," applying radical acceptance, using the "DEAR MAN" technique, and utilizing an emotion regulation skill called "opposite action." Finally, she explains how the tenets of DBT offer benefits to anyone, and she provides insights and resources for people wanting to further explore DBT.</p> <p>We discuss:</p> <ul> <li>The basics of dialectical behavior therapy (DBT) and how it differs from cognitive behavioral therapy (CBT) [3:00];</li> <li>Treating depression with CBT: history, effectiveness, and how it laid the groundwork for DBT [8:15];</li> <li>Marsha Linehan's inspiration for developing DBT [16:00];</li> <li>Explaining borderline personality disorder (and associated conditions) through the lens of DBT [20:00];</li> <li>How work with suicidal patients led to the development of DBT—a dialectic between change and acceptance [35:30];</li> <li>Details of DBT: defining the term "dialectical" and how to access the "wise mind" [44:30];</li> <li>Practicing mindfulness and radical acceptance in the context of DBT [51:00];</li> <li>Applying "radical acceptance" to tragic scenarios [1:02:00];</li> <li>The five domains of skills taught in DBT [1:07:15];</li> <li>Why Marsha chose borderline personality disorder as her focus when developing DBT [1:13:30];</li> <li>Is there any benefit in doing DBT for someone without a pathological condition? [1:15:45];</li> <li>The DEAR MAN skill of DBT [1:20:00];</li> <li>Adapting DBT skills for adolescents and families [1:31:00];</li> <li>Identifying vulnerability factors, increasing distress tolerance, and the impact of physical pain [1:33:45];</li> <li>The DBT chain analysis: assessing problem behaviors and identifying vulnerability factors [1:44:30];</li> <li>Why the regulation of emotions can be so challenging [1:50:30];</li> <li>The importance of mindfulness skills in DBT [1:53:30];</li> <li>Opposite action: an emotion regulation skill [1:57:00];</li> <li>Advice for those wanting to explore DBT [2:03:15];</li> <li>Finding a well-trained DBT therapist [2:08:15];</li> <li>More.</li> </ul> <p>Connect With Peter on <a href="https://twitter.com/PeterAttiaMD">Twitter</a>, <a href="https://www.instagram.com/peterattiamd/">Instagram</a>, <a href="https://www.facebook.com/peterattiamd/">Facebook</a> and <a href="https://www.youtube.com/channel/UC8kGsMa0LygSX9nkBcBH1Sg">YouTube</a></p>
Actionable Insights

1. Embrace Change and Acceptance Dialectic

Recognize that both solving life’s problems and accepting what cannot be changed are crucial for reducing distress and misery. Strive to synthesize these two seemingly opposing forces.

2. Cultivate Wise Mind for Decisions

Avoid being solely controlled by emotions (emotion mind) or facts/logic (reasonable mind). Instead, strive to synthesize both, finding what is valid in each, to make decisions that are effective and aligned with your values.

3. Employ Opposite Action for Emotions

When an emotion is intense or doesn’t fit the situation, act contrary to the urges associated with that emotion (e.g., activate when sad, approach when fearful, disclose when ashamed). This sends feedback to your brain to change how you feel.

4. Practice Radical Acceptance of Moment

Fully accept yourself, situations, and the present moment exactly as they are, without judgment or resistance. This practice can reduce suffering and potentially allow you to experience joy.

5. Actively ‘Turn the Mind’ Towards Acceptance

Radical acceptance is an active, continuous process of choosing to move towards acceptance, often multiple times a minute. When faced with a choice between acceptance and refusal, willingly choose the path of acceptance.

6. Reduce Suffering by Focusing Present

Recognize that much suffering comes from ruminating on the past or worrying about the future. Actively let go of these thoughts and experience the current moment to significantly reduce distress.

7. Acceptance Doesn’t Eliminate Pain

Understand that life inherently involves pain (emotional and physical), and acceptance is not about eradicating it. Instead, it’s about not adding to suffering by trying to escape or deny that pain.

8. Consider Cost of Non-Acceptance

When struggling with radical acceptance, ask yourself, ‘What’s the alternative?’ Recognize that refusing to accept reality often consumes more mental resources and leads to greater long-term suffering.

9. Separate Acceptance from Problem-Solving

In a moment of crisis or high distress, focus on accepting the current reality rather than trying to problem-solve for the future. Effective problem-solving is difficult when emotions are overwhelming.

10. Practice Dialectical Thinking

Acknowledge contradictions and tensions, find validity in opposing viewpoints, and seek a synthesis that integrates both perspectives. This approach helps avoid conflict and fosters a more nuanced understanding.

11. Synthesis Is Not Compromise

When seeking a ‘wise mind’ solution, aim for a new perspective that validates and integrates both opposing sides. This is more profound than simply meeting in the middle.

12. Identify Personal Vulnerability Factors

Recognize what makes you susceptible to negative emotions, stress, or distress (e.g., lack of sleep, excessive commitments). Proactively manage these factors to improve emotional regulation and overall well-being.

13. Conduct Chain Analysis for Behaviors

To change undesirable behaviors, systematically analyze the chain of events, thoughts, and actions that lead up to the behavior, as well as its consequences. This helps identify precise points for intervention.

14. Develop Skills in Five Domains

Focus on improving mindfulness (present moment awareness), interpersonal effectiveness (asking/saying no), emotion regulation (managing emotions), distress tolerance (handling stress without worsening it), and self-management (doing what you need to do).

15. Use DEAR MAN for Communication

Employ the DEAR MAN (Describe, Express, Assert, Reinforce; Mindful, Appear confident, Negotiate) framework to effectively ask for what you want or say no. This increases the likelihood of a positive outcome in interpersonal interactions.

16. Directly Assert Needs or Desires

Overcome the challenge of indirect communication by clearly and directly stating what you want or need. Avoid expecting others to infer your wishes.

17. Reinforce Desired Outcomes for Others

When making a request, explicitly state the benefits or rewards for the other person if they comply. This reinforcement can be tangible or simply your appreciation.

18. Describe Situations Concisely, Without Judgment

When using DEAR MAN, state the facts of the situation briefly and objectively. Avoid interpretations or judgments to maintain the other person’s engagement and clarity.

19. Clearly Express Your Feelings

In interpersonal interactions, explicitly state your emotions related to the situation. Do so without adding judgments or accusations to foster clearer communication.

20. Counter Emotional Urges with Opposite Actions

If sad, activate instead of withdrawing. If fearful, approach instead of running. If ashamed, disclose or confront instead of hiding. These specific opposite actions help shift your emotional state.

21. Combat Isolation by Engaging Family

When feeling the desire to withdraw, actively force yourself to engage with loved ones. This opposite action can lead to improved mood and connection, counteracting the urge to isolate.

22. Commit Fully to Opposite Action

When performing an opposite action, engage not just physically but also mentally. Fully immerse yourself in the activity to effectively change your emotional state.

23. Practice Mindfulness to Separate Thoughts

Engage in mindfulness to identify thoughts and create a distance between yourself and those thoughts. This practice prevents thoughts from overwhelming you.

24. Cultivate Personal Mindfulness Practice

Engage in any form of mindfulness (e.g., yoga, mindful walking, formal meditation) to strengthen your ‘mindfulness muscle’. This enhances present moment awareness and emotional regulation.

25. Practice Self-Validation for Pain

Instead of questioning or rejecting your pain (‘Why am I feeling this way?’), validate your experience by acknowledging, ‘Of course, I feel this way; it’s okay to feel this way.’ This reduces secondary suffering.

26. Use ‘It’s Okay to Feel This’

When experiencing any emotion or pain, simply tell yourself, ‘It’s okay to feel this.’ This simple phrase can be a powerful experience for self-validation and reducing resistance to your current experience.

27. Manage Physical Pain as Vulnerability

Acknowledge that physical pain can increase irritability and reduce patience. During such times, reduce demands on yourself, practice self-kindness, and explicitly communicate your needs to others.

28. Communicate Internal Pain to Others

Since physical pain is often internal, practice interpersonal effectiveness by explicitly verbalizing your suffering to others. This allows you to set boundaries or request space to manage your emotional state.

29. Improve Self-Management for Effectiveness

Develop the ability to consistently perform necessary tasks, even when undesirable. This includes maintaining routines like waking up early, exercising, and eating healthy.

30. Challenge Emotional Myths

Identify and question mistaken beliefs about emotions that hinder your ability to regulate them. These myths can perpetuate dysregulation and prevent effective coping.

31. Be Aware of Behavioral Reinforcement

Recognize how certain emotional behaviors (e.g., anger, crying) might be subtly reinforced by others’ responses. This awareness helps you understand why these behaviors might increase in specific contexts.

32. Practice Identifying Full Range Emotions

Move beyond basic emotions like anger to recognize and label more nuanced feelings such as helplessness, sadness, hurt, and fear. This is a crucial step in effective emotion regulation.

33. Apply CBT Principles to Problems

Focus on present thoughts and behaviors contributing to issues, then work to modify or change them. For example, with insomnia, identify and modify thoughts/behaviors hindering sleep.

34. Overcome Fears via Exposure, Thoughts

Instead of avoiding feared situations, repeatedly expose yourself to them to learn you can handle it and that the feared outcome won’t occur. Simultaneously practice alternative, competing thoughts.

35. Combat Depression: Change Thoughts, Activity

Work to make negative thoughts more balanced and evidence-based. Counter the tendency to retreat by getting active and systematically solving problems contributing to depression.

36. Model Regulated Behavior for Children

Demonstrate calm and skillful responses to challenges, rather than resorting to authoritarian or dysregulated reactions. This teaches children healthier coping mechanisms through example.

37. Parents Learn DBT Skills with Children

If children are learning DBT, parents and caregivers should also participate in skills training. These skills are beneficial for everyone and can significantly improve family dynamics.

38. Explore DBT Skills Independently First

Start by exposing yourself to DBT skills through videos or workbooks to see if they resonate and if you can apply them on your own. If you struggle, then seek professional help.

39. Consider DBT Skills for Well-being

Even without a formal diagnosis, many individuals can benefit from learning and applying DBT skills. These skills can improve various aspects of their lives and emotional health.

40. Verify DBT Therapist’s Consultation Team

A key indicator of a well-trained DBT therapist is their participation in a weekly consultation team meeting with other DBT therapists. This helps ensure adherence to the model and ongoing professional development.

41. Consider Certified DBT Therapists

When seeking a DBT therapist, look for those certified by the Linehan Board of Certification (LBC) as a strong indicator of adherence to standards. However, note that uncertified therapists can also be effective.