Navigating Dialectical Behavior Therapy (DBT) with an Expert Therapist

Navigating Dialectical Behavior Therapy (DBT) with an Expert Therapist

Speaker A: The following podcast is part of the MindBodySpirit FM podcast network.

Helen Sneed: Welcome welcome to our award winning podcast, Mental Health, Hope and Recovery. I'm Helen Sneed.

Valerie Milburn: And I'm Valerie Milburn.

Helen Sneed: We both have fought and overcome severe chronic mental illnesses. Our podcast offers a unique approach to mental health conditions. We provide practical skills, guest experts, and inspirational true stories of recovery. Our knowledge is up close and personal.

Valerie Milburn: Helen and I are your peers. We're not doctors, therapists or social workers. We're not professionals, but we are experts. We are experts in our own lived experience with multiple mental health diagnoses and symptoms. Please join us on our journey.

Helen Sneed: We live in recovery, so can you.

Valerie Milburn: This podcast does not provide medical advice. The information presented is not intended to be a substitute for or relied upon as medical advice, diagnosis or treatment. The podcast is for informational purposes only. Always seek the advice of your physician or other qualified health providers with any health related questions you may have.

Helen Sneed: Welcome to episode 62, navigating dialectical behavior Therapy with an Expert Therapist. We are so pleased to offer a second full episode about DBT now. In our first, Valerie and I explored the origins, development, methods and ultimate global impact of this treatment. Created by Marshall Linehan, DBT has become an international treatment phenomenon that has saved hundreds of thousands of individuals fighting for mental health and life itself. Time Magazine named DBT one of the top 100 scientific discoveries in 2011. We strongly urge you to listen to this first episode with its message of powerful techniques and skills that can lead to hope for recovery and a life worth living.

Valerie Milburn: Let me give you an overview of dialectical behavior therapy. As Helen said, our last episode is devoted entirely to dbt. So here's A Quick Overview DBT is an evidence based treatment that can help individuals change unhelpful patterns of thinking and behavior. DBT helps people accept themselves and manage emotions to live more effectively. Here are the core goals of dbt. The first core goal of DBT is to balance acceptance of the present with motivation for change and that balancing of acceptance of the present is mindfulness. The second goal is to manage intense emotions and impulsive behaviors. And the third goal is to build mindfulness, distress tolerance, emotion regulation, communication skills, and boundary setting. Learning skills is central to the effectiveness of dbt. There are two kinds of skills Acceptance Skills to give the client practical ways to accept the problems they have and change Skills to solve the problems they have. Skills are action oriented. Marsha Linehan said, you can't think yourself into new ways of acting. You can only act yourself into new ways of thinking. DBT skills are life skills to be used throughout one's years to reach and sustain a life worth living.

Helen Sneed: And now it's my great honor and pleasure to introduce the expert we promised, Penny Krueger. Penny, we are delighted to have you join us and look forward to your insights and expertise about dbt. You bring such unique ability and perspectives to

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Helen Sneed: inform us today. So welcome. Welcome to our podcast.

Speaker A: Thank you for having me.

Valerie Milburn: Yes, welcome. We really are just thrilled to have you here.

Speaker A: I'm excited to be here with you guys as well.

Helen Sneed: Well Penny, I first want to tell our listeners about your many roles in the field of dbt. Penny Krueger, lcsws, completed her Master's in Social Work at Tulane University in New Orleans, her native city. She has been practicing clinical social work for 30 years at all levels of clinical care with a variety of clinical areas including mood disorders, sexual trauma, sexual compulsivity, domestic violence, offender treatment, and personality disorders. Penny is intensively trained in both dialectical behavior therapy and radically open DBT. In 2006, she started the first adult DBT intensive outpatient program in Austin, Texas at Ascension Seton Behavioral Health. She was the clinical lead for this program until 2020 where she trained and supervised many of the current practicing DBT clinicians in the Austin area. She is currently an affiliate faculty member for UT Dell Medical School Department of Psychiatry, where she teaches DBT and RO DBT to the psychiatric residents and social workers. She remains the Senior Clinical Director of Austin DBT Associates that she co founded in 2016 to help train clinicians to provide adherent DBT and RO DBT treatment in an outpatient setting. She continues to see clients in her own private practice Penny's passion is providing training and consultation for clinicians and agencies across Texas who want to adapt DBT and RODBT treatment to their treatment settings. Well, that's impressive, Penny. So it's time to get going. Let's start at the beginning of your remarkable career. Tell us something about your background. What interested you in becoming a therapist?

Speaker A: Well, for me, I think it was just sort of a series of lucky events that came into play. Obviously, I grew up in New Orleans, so it's not that I'm any stranger to dealing with things that have to do with addiction and where I grew up. However, really what happened was I. I was on scholarship in college, and I had to work for my. At the school at LSU in Baton Rouge, and they assigned me to work with a neuropsycholog who taught abnormal psychology. And at that point, I really became hooked, is what I say. And I had the fortunate circumstances of when I moved back to New Orleans after I graduated to work at a psychiatric hospital that had. Where Masters and Johnson had a program that, you know, treated patients from all over the world in sexual trauma, sexual compulsivity, and there was an eating disorder program as well, and chemical dependency. And so I really had the fortunate opportunity to be able to work with a lot of specialized populations. And of course, this is where I first began working with folks who were diagnosed with borderline personality disorder. And at this time, I really obviously didn't have the experience. I was still a student myself and learning, but I was learning about myself in terms of some of the things that I felt drawn to and felt interested and passionate about doing and working with at that time. It was also, though, at that time that. So I was. I decided to go to Tulane at that point. I was finishing my education to become an LCSW so that I could continue this work. But it was also during that time in working in hospitals that I had my first experiences of noticing how sometimes there were things that were like being documented in charts about folks that were having more difficult behaviors on the unit or that had been diagnosed with personality disorders that were not necessarily being talked about directly with the patient necessarily. And so it was my first experience of noticing just some of the judgments that come up and how it can impact treatment and how treatment is playing out. And so that was just something I didn't have any frame of reference about what to do with, but it was something that impacted me in terms of as my

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Speaker A: movement going forward in my career with dbt.

Valerie Milburn: Well, we won't name that hospital, but I.

Speaker A: Because it can happen at any hospital.

Valerie Milburn: Right. But no, I spent nine weeks at that hospital and went through the Master's and Johnson program, which you and I didn't know about each other, but that's where I was first introduced into dbt. And I'm just wondering, how did you become involved in dialectical behavior therapy and what persuaded you that it was such a valuable treatment method?

Speaker A: Yes, so, and actually that was my first introduction was at that program. However, I wasn't doing it at that time. It was, you know, a forensic psychologist who started that program there. And again, I was still learning, but I was, I was intrigued and loved seeing some of the things that they were doing to help folks to be able to live outside of the hospital. Because at that time people could be in the hospital for a lot longer. And however, even though they could be there for six months or even a year, we still had folks who continued to be re hospitalized due to suicidality, self injury, things of that nature. And so I was really drawn to the practicality of really helping folks to be able to have skills to build a life worth living in the present. And so when I, after I graduated and I worked for, you know, several more years though, I was always in a behavioral modalities because I was working with juvenile sex offender program and I worked in a domestic violence program and both of those were really behavioral based as well. But when I came to Austin, Texas, I started working at the intensive outpatient at Ascension Seton and they did not have a specific DBT program at that time. But however, there were just a subset of patients that I felt like clinicians either were having difficulty working with, or that the patients were dropping out of treatment early, or they were having so much difficulty feeling dysregulated during the group treatment that they weren't making progress and so that the patient was feeling demoralized or the clinicians felt like they weren't making progress. And so I remembered that experience, my early experience with dbt and I was lucky enough to have a really supportive administration that allowed me to go. I asked if I could go and get some training so that I might come back and be able to better serve these clients that I felt like were being underserved.

Valerie Milburn: Helen, you and I can certainly relate to the feeling dysregulated in therapy sessions and feeling demoralized. So, you know, it's wonderful to have that validated, that it can be seen.

Helen Sneed: And not being able to make anything of the therapy because you're so dysregulated, you couldn't Hardly tie your shoes, you know, that kind of thing.

Speaker A: Yes.

Helen Sneed: So, okay, so you, you came up to the brink of dbt. Tell us about your own training experience with dbt. Because it must be something, I mean, will you do it now?

Speaker A: Well, and at that time where it was really open, it was all still forming as far as. Because I was lucky enough to get to meet Marcia in her early days when I think when she came to Houston once and, and I got to see her do an emotion regulation training update as well. And you know, everything was still forming at that time. And so I connected with a couple of other clinicians in the Austin area that had been doing some dbt, but they weren't on a team. They were kind of all doing it in isolation and so contacted them and you know, got together with them so that we could form a team. And at that time, the, I think the. It was a little bit more stringent what you had to do before you went to intensive. So we had to be together for about a year. We were together over a year, kind of going through manual studying, also practicing so that we could make our team application to go to the intensive. And so which was a 10 day at that time, where you go for a week and then you come home for six months and you've got a lot of application and homework to do with your patients and then you go back for the second half. And so I, I did that and then of course had to continue doing many other DBT trainings as well, adjunct ones to continue my learning. But I brought it and then began to do my implementation at Ascension Seton, where I started the DBT Intensive Outpatient, beginning to apply what I've learned and also at that time doing some data to kind of help justify what I was trying to do to our administration. So I did just a little bit of data collection where many of our patients at that time were stepping down from inpatient and so collecting data around if they were re hospitalized during the treatment and if they were, was it for a shorter stay?

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Speaker A: Like, did they stay for a shorter amount of days before they could step back down to me in IOP and complete treatment? And also the amount of incidents of reported self injury during the treatment and they went down. All of those variables did go down.

Helen Sneed: So you could prove that the DBT treatment was beneficial.

Speaker A: Exactly, you could prove it, which of.

Helen Sneed: Course is the whole important thing.

Speaker A: Yes, yes, I loved having that observable data because as you know, in our field things are pretty subjective. And so I think I am somebody who really likes that objective data and having something really tangible to give to my clients.

Valerie Milburn: That's wonderful. That's really important. So you were in at the beginning, and I'd love to know if you see a difference in the professional opinion of DBT from those early years of practice to the present. I mean, and along those lines, are there misconceptions in the field?

Speaker A: Oh, yeah, absolutely. Especially early on, definitely. When I was first starting dbt, I think that people were so taken. They were sort of put off by the fact that they felt like it was a structured treatment and so felt that it was going to be like a workbook treatment that was took away from doing sort of the deeper depth exploration and doing all of that good process work. And, you know, my case to them was that if you have a client, though, who is really struggling to even get through that process work and you're already, you're burning out from the client or the client is at risk of dropping out of the treatment, why would we not address the things that are on fire first? Something that is really causing so much pain and suffering in my patient's daily life. Right. Like, there's a lot of value to be done in trauma work or family of origin work. Right. But we just believe that there's an order of business in the sense of if we aren't start feeling some improvement in, you know, my current daily living, it's really hard to have the space and the ability to tolerate doing that other work. So, you know, I just like to explain it in true dialectics. It's not an either or, it's a both. And. And yes, we are more structured, though, about the order of how we want to get there. And sometimes, you know, I have to work on that orientation and that commitment with my patients. Even though they have chosen to come to me for DBT because they are used to moving into, straight into doing that process work or doing trauma work.

Helen Sneed: And things within your own practice. Do you find the demand for DBT has expanded over the years? And if so, why do you think this has happened?

Speaker A: Well, I think that number one, because I think DBT has definitely become more widely accepted as a really effective intervention for clients, especially for clients, that I think, where both the client and the therapists are feeling like that they've been struggling and making progress in traditional treatments. I think that with when I first started out and we started our team, there was literally like maybe, I don't know, there was five of us on our team and there was maybe eight total in the Austin Area. Okay. And I believe that you really need to be on a team because it is, you know, it really. The team is what treats the clinician. It's what treats us. I think that's a difference between DBT and other therapies is that we really believe in treating the clinician and holding the clinician accountable to our own therapy. Interfering behaviors and being aware of those. At that time, there was already a demand that was hard for us to meet because there were so few of us. And of course, then over the years is that many were training with me through the intensive outpatient because we went from one group to 12 groups. We had 12 DBT groups at one time.

Valerie Milburn: Wow.

Speaker A: Our highest. And we. We started the first DBT IOP embedded at a university at UT at University of Texas. And so we had one there as well, where we had our clinicians. So we really had a lot of good work doing. So a lot of clinicians and trainees all came through students who would learn and become, you know, really effective at doing DBT and then be able to go out into the community. Since then.

Valerie Milburn: The.

Speaker A: The demand has only continued to increase, for sure. I get lots and lots of calls from all over the place for folks who are looking for DBT programming and DBT groups and DBT clinicians and having. And, you know, having to find people who have had good training just because there's a lot of people who may have done a training, and that's fine, too. I don't have any judgment about that. It's more that I just want them, if they're going to take a case that's going to have probably more complexity, to make sure that they feel like they. They have the structure to be able to hold the case so that it doesn't feel demoralizing to the patient

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Speaker A: and to the clinician.

Helen Sneed: Do you think that some of the. This growing demand comes from the fact that over time, DBT has become more legitimate in the eyes of the treatment field and community?

Speaker A: Oh, yes. I think they realize.

Helen Sneed: So they're also. They might also be telling their patients, you want to try DBT as well. Correct.

Speaker A: I think they're using us more particularly as an adjunct treatment. Like I do a lot of trainings with other practices. Right. Where they might do general therapy, they might be doing, you know, psychodynamic work, they might be doing, you know, even OCD treatment and eating disorder treatment, but they will use us as an adjunct because sometimes the clients are engaging in behaviors that are either disrupting the treatment that they need Right. Or there's some other behaviors that are making them. It more difficult for them to work with the patient. And so we will work in adjunct. Like, sometimes I've had a patient who maybe was in trauma treatment doing EMDR and maybe started to decompensate during the emdr. And so they might come to me for stabilization and getting them ready if they want to go back and return and do some more EMDR work. Right. So there's a lot of different ways that we can use that. So I think that they. There's definitely a lot more use in terms of us working, which I love working together as opposed to being in either or. Because I think our patients, because they have multiple diagnoses and multiple problems, they're sent to so many different specialists and everything being the next panacea, that's going to help. And, you know, I just, I believe in being as realistic and, you know, transparent, which is what I love about dbt. DBT is a very transparent treatment. There's. I always tell my patients, there's nothing that I'm going to be doing that I won't be saying directly to you, which I think increases trust. Right. Because.

Valerie Milburn: Right.

Helen Sneed: Well, it's very. And I find it. I would have found it very unusual in my day to feel like I had that kind of relationship where I would be told these things with great transparency.

Speaker A: Everything was like, on a pad, like, behind this, no one knew what was being written. And I can't imagine how much that increased their anxiety. Right.

Helen Sneed: And curiosity. What did I say this time? You know?

Speaker A: Exactly. Exactly. So, yes. And I also, I think that I. I think that what's been fabulous, too, is that it has. It has become trans. Diagnostic. Right. So the way I, you know, I know this is another thing y' all had asked me about, but, you know, it is now people are seeing it beyond just for bpd. And it is the way I conceptualize it for folks when they call me and they're like, do you think TBT would be a good fit for me? And I say, like, you know, here's what DBT was built for. Okay. It was initially built for. Yes. For people that had been diagnosed with borderline Personality disorder, which, you know, again, I don't consider that a static thing either. But however, the. What I would say is that DBT is a very useful intervention and treatment for folks who in general feel like they struggle with more pervasive emotional dysregulation. They just feel everything more intensely. And also possibly some behaviors that are impacting quality of life. And I always say those can be on either side. They can be impulsive behaviors. Right. More externalized that are causing fallout, or they might be more internalized, like avoidance behaviors that are causing them significant fallout. And so I think in, in that realm, right. That is where DBT was built to be helpful.

Valerie Milburn: So say another therapist, one does refer a patient to you and you need to explain it DBT in a simple way, particularly to an individual who knows very little about it.

Speaker A: It.

Valerie Milburn: What's your elevator pitch?

Speaker A: That's probably, you probably just got really. That is what I say. I say like, if you're struggling, feeling like that, you are really having difficulty managing the intensity of emotions, which again, we all do. I think that for those that come to dbt, they just feel like it's happening a lot more frequently. And they might also just feel like they are having certain what we would call and I'll say this to the patient, right. But that we would call target behaviors that are just impacting their quality of life. And they're feeling really frustrated about sort of how to get, you know, in front of this and how to feel like, you know, that it's reducing the impact. And so that is what I would say to them. And most people when I say that, just that they will say like, yes, oh, yes. I can see how that would be helpful.

Valerie Milburn: So good.

Valerie Milburn: So good. So good.

Helen Sneed: This is a question I feel like I'm asking on behalf of many, many people. Can you educate our listeners on just the basics of dbt? I mean even its name can be bewildering, you know.

Speaker A: Yes. Dialectical behavior therapy or as my patients will tell me, diabolical behavior therapies. Yes. So okay, so and kind of, I guess connecting a little bit to what the previous question is, just that, you know, when they're like so what does it mean, right, to be in dbt? What does that mean? You know, and I'm saying like you're, you're basically, you're committing, right. You're making a commitment, right. To be in a more structured treatment where it is collaborative. I tell them and though there is, there is sort of an order of business in terms of what we would call the target hierarchy so that you and I are going to collaborate around sort of what the agreed upon targets are. However, any targets, right. That are in like the area of being more life threatening are going to be non negotiable in, in order to be a part of this treatment. Right. Like you have to commit to staying alive for the treatment. Because we would say if the patient's not alive, right, treatment's a moot point. We're very direct about that. And so. And Marshall Inan's direct about that. Right. We are getting that commitment that that is the priority and any other self destructive behaviors would be the priority. And so we collaborate on what those are. We talk about if there's any therapy, interfering behaviors. And that's usually, they're usually only going to have knowledge of that if they've had some past therapy or maybe some therapy that's been disrupted. And so we'll try and get those on the table again. That's usually a direct conversation that I think other therapies don't normally have. And because I want to make it less likely for this treatment to get disrupted. Right. So want to talk about the things that they feel like have blown up past therapy either by the therapist or by the patient. It's a both and right. We, we have just as many, I tell them we have just as many therapy interfering behaviors. And I tell them I'll Be talking to my team about mine. And if you observe one that you see coming up for me, you know, and let me know, I will take it to my team. Right. And then we talk about, you know, the quality of life behaviors that are impacting life. And so these may not be life threatening, but they are impacting quality of life. And again, those are more collaborative that we will talk about as far as how we're going to. What the sort of the order of business is. And then we talk about the structure of the treatment that they are agreeing to do. Skills training group so that they have a place. And I tell them it's like a class. That's a big deal, that it's not a process group. You know, some patients really like that, that it's a class and that it's not going to be another process group. For some patients that's more of an orientation. They really want to have that place to process. And it's not that we don't talk about anything, it's just more. It is the goal is to teach skills in. And that is so that in our individual work, we can be working on application. Right. We can get really busy with application and making sure that we are bringing down again very objectively. Right. I don't want it to be my patient having to think about, am I, is this therapy helping me or not helping me? Am I? You know, I will say, well, let's, let's evaluate. Right. The targets are based on intensity, frequency and duration. Do we see these things getting better or are they not? Because if they're not, then, you know, again, that's just another problem to solve. For my opinion, I don't think that has to mean that my patient isn't working hard enough or that the therapy isn't working, but that it's just another problem for us to solve.

Valerie Milburn: And intensity, frequency and duration. Give me an example, please. Intensity and frequency and duration.

Speaker A: Sure. Of whatever

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Speaker A: the behavior is they're working on. So let's just say, let's take substance abuse.

Valerie Milburn: Okay.

Speaker A: So let's say there is binge substance abuse. Many of my patients are going to have more binge substance use. If they have more chronic substance use and it's interfering with them benefiting from the treatment, we might have to get. Send them to get more sobriety under their belt. But if it's binge substance use, then we are looking at. Right. Right. Frequency of relapses, we're looking at how long the relapse lasted. Right. And the intensity. Right. Did they. Right. Did they use all the things or was it like, you know, a few things or less use. Right. Than they would have typically used? Did they show up at work on Monday or did they end up, you know, calling in and having a whole lot more fallout to it? So we're evaluating that whole thing so we could really instead of just evalu because the patient's usually going to be demoralized. Right. Like I had another relapse. But we really to want to evaluate the quality of it. Right. We want it to be a better relapse.

Valerie Milburn: Okay, that makes sense. It's a good, good explanation. Thank you. Now, you talked about skills. It's a class. What about skills? What about symptoms and issues? Are the skills designed to address. Can you give the name of a couple of skills that you think are most effective in your experience?

Speaker A: Sure, sure. So definitely you guys, I know. Talked about in your previous episode, the four primary skill modules in terms of core mindfulness and distress tolerance and emotion regulation and interpersonal effectiveness. Let me first just speak to what they are meant to address. When I think about. Obviously they all address a number of things and we use them all in conjunction. However, there's a couple of things that I think about in particular in terms of like when I think about, you know, core mindfulness. Right. You know, that is the ability. Right. To be able, as y' all talked about, to observe something with more distance. So. Right. So that it helps to be able to at least even talk about it and bring down. It's already going to help with reducing disregulation when we're practicing core mindfulness. However, it can be in particularly helpful skills in terms of like in group, when people are trying to manage dissociation. Right. Also people that really struggle with a lot of obsessive rumination. Right. Those can be very helpful as well. We are looking at distress tolerance in terms of. That's part of helping people to be able to reduce, again, sort of impulsive behaviors that are causing more fallout. Right. They're already suffering, but because of difficulty tolerating what's already happening. Right. Engaging in things that then cause more fallout. So we are often using them for their stage one targets, is what we would say. So temper outbursts, self injury, suicidal ideation. It could also be on the other side though, it could be on avoidance behaviors that are causing a lot of fallout to quality of life as well. So we are. And some of our. The favorites, distress tolerance are usually favorite skills because I think they're more concrete and immediate. Right. I think that in the beginning of treatment when we're using distress tolerance, I think that people can begin to experience and observe some of the helpfulness kind of more quickly when they're using distress tolerance. So those tend to be a more favorite. Whereas core mindfulness, right. Can feel a little bit more sort of esoteric. So sometimes they're like, how do I know when I'm in wise mind, right? Sometimes I can feel like how do I know when I'm doing this correctly, right? It's like there is no correctly. It's just a process, a process of being able to do that. So, you know, some of the skills lend themselves a little bit more to I think observable action which they, they tend to be drawn to first. Like y' all talked about, like opposite to emotion action. That is a favorite, right? Radical acceptance is both loved and hated, right? Yes, well, radical, once, once you get.

Helen Sneed: There, it is like it changes my whole world. It changed my whole worldview. But I, it, I just didn't think it would ever happen happen. I didn't even want it. I didn't want to radically accept all this horrible stuff. Who wants to.

Speaker A: Yes, exactly. Who wants to radically accept such a painful reality, right? And so yeah, whenever we would teach that module in iop, I know the clinicians would be like, we're so nervous. It's radical acceptance week. Because we knew there was definitely going to be a large explosion that first day. And the other favorites, though, I have to say, I'll say they're probably therapists. Therapist favorites. They may not necessarily be my patients favorites right away are interpersonal effectiveness. And I'll tell you why. Because with the interpersonal effectiveness skills, right, one of the number one things that can lead

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Speaker A: to a prompting event, a prompting event that leads to more self destructive behaviors, particularly suicidal threats or suicide attempts or gestures or self injury tends to be be interpersonal conflict, okay? Whether it be with family relationships, things like that, that is a primary prompting event. If I went to the psychiatric unit right now, right, There would be a large percentage if they had been put in there for a recent attempt, it would have been on the back end of interpersonal conflict, okay? And so the feeling of the ability to increase trust in ourselves, to feel more skillful, that we have have hope in being able to navigate the interpersonal environment is, is huge, okay? It isn't just about teaching assertiveness, it's about teaching skills to understand the nuance of interpersonal effectiveness. I, in my early career, right, I had done tons of boundary work, but really Marshall, in Hand did a much better job, I think, at leaning into the nuance of looking at the different priorities of interpersonal personal effectiveness, whether that be around maintaining the relationship, self respect or, or you know, getting what we want. And some of my patients, right. We're trying to lower the intensity of, of how they're going to assert in that moment. Right. Because I want them to be heard. The only priority in interpersonal effectiveness that I tell my patients is that I'm never here to make you be like, or to feel like you're going to be like, sort of compliant, polite, you know, people who, who avoid conflict. What I. The only thing that is the reason that we want to learn these skills and feel really effective at them is because I want the content of what you have to say to be heard. Because often the content that they want to communicate is already right on. However, the package it's coming in is making them be dismissed by the environment.

Valerie Milburn: Yeah.

Helen Sneed: Just not heard, you know, whatever.

Speaker A: Very painful experience, you know.

Helen Sneed: Yeah.

Speaker A: So I love that. I love interpersonal effectiveness.

Helen Sneed: Okay, well, I, maybe I should come back and have a little more, I'm not sure, have a get, get, get back for a little, you know, brush up my Shakespeare or whatever you want.

Speaker A: Don't we all?

Helen Sneed: Yeah. Now you kind of touched on this earlier, but is there a certain approach that you take with a client Client. If it's a person who's had, say, some serious setbacks and really kind of wants to, to quit, but needs to stick it out until they can feel and see progress, is there a certain way to persuade someone to stick with it?

Speaker A: Oh, yes. Well, I think that's what we do a lot of. I always say, like we are basically really, we are cheerleaders. We're cheerleaders, but we don't want to be too positive because we believe that positive is only the other end of the dialectic of negative, of being negative. So we're always trying to find, of synthesis makes us a little bit different than standard CBT because we're not trying to turn sort of negative thoughts into positive thoughts necessarily where. That's why we practice acceptance of what is. So yes, obviously that is a big part of. For many of our clients that come into DBT by the time they've got to us. In dbt, especially in my IOP program, it was not uncommon for them to have had many of treatments and for them to feel really like if this doesn't work, that's, that's it. Right. I don't know if I want to Live and you know, it's like no pressure. It is. And so often there is. We cope ahead at the beginning of the treatment, right. We're orienting them to urges to quit treatment. That, that is going to be expected, Right. Also, you know, the urge to move into premature termination, right. To be upset, right? You're going to get upset with me, right? I know for sure I'm going to disappoint at some point, right. And we have to cope ahead about how we're going to work through that. And if they are in that space of demor realization where the urge is to quit, right. This is where from, you know, a DBT perspective we would talk about, you know, from a validation, just being radically genuine with the patient. Right. Kind of dropping the sort of like maybe that therapist role a little bit in terms of really being able to sit with them in that and validate that feeling of demoralization. Right. I don't want to try and cheerlead them out of that necessarily. In terms of trying to convince them. I would really want to validate, you know, that feeling of being there and that sense of like that nothing is going to get better or change and that I, however, I would say again, and I would say, and I'm going to have to agree to disagree with you, that the effective way to manage this is to bail. I think this is when again, this is what DBT was built for. I want to remind you who it was built for. It was built for initially for women who were chronically suicidal. Suicidal and who

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Speaker A: were self injuring and who are in great despair.

Valerie Milburn: Okay?

Speaker A: So this is what it was built for. And I want to urge you to hang in. And if you hang in, right, I will be there with you to help problem solve. And so really, you know, I think it's just that space of really getting real with them about that. Their, their, their misery makes perfect sense. I don't want it to be that. Sometimes I think, you know, know, many of my patients have heard things like, well, maybe you're just not ready, right, to get better right now. Or maybe this just isn't the right treatment for you. Or maybe, you know, to me that become just sort of a polite push away. And I just want to say if I thought that you leaving me right now would be a pathway to reducing your suffering, I would say go be free. However, right. If your suffering is going to stay the same or only increase, I would say, why don't you hang in here with me, right?

Valerie Milburn: I love that. I love a couple of Things you said, your misery makes perfect sense. That's a such a validating statement rather than maybe this isn't the right treatment for you. You know the. Some of the things you said are really, really meaningful. And also love the term cope ahead. Never heard it before but without even knowing it, I've been using it with my 6 year old grandson. Basketball games where he's the only 6 year old with a bunch of 8 year olds and it's like, okay, this is what's happen and this is how you're going to deal with it. And so we've been coping ahead on the basketball court. Six year old. So you just mentioned that DBT was originally created for women and explain, you know, the situation they were in and why it was created. So we know it's now used for many other mental health disorders. Can you touch on that topic for a minute?

Speaker A: But place and for men as well.

Valerie Milburn: Absolutely.

Speaker A: Started out I had a hundred percent women. For a long time I would have just a few men. And now I've got some groups that are all men and you know, definitely. Oh yeah, we went to 50% at least. Well, there's such a gender bias right there and how inaccurate personality disorders are diagnosed. Right. Like females are tons more likely to be diagnosed with BPD and men get diagnosed with npd. So right there we know there's really a lot of gender bias and how people label things. And so. And this is what I want to say earlier about diagnosis. It came to me is that, and when I talk to the, to the residents and to the doctors that I work with, I say like, you know, the, and the therapist, it's like because my clients have so many different diagnoses, I think that treatment needs to be guided by making sure that we have the right target behaviors that are causing them the most painful fallout of their life and the mood symptoms that are causing them the most painful fallout. Right now because I could have 10 people, guys that all have a diagnosis of complex PTSD or 10 people with a diagnosis of bipolar 1 or bipolar 2 and they are going to have very different levels of functioning. They're going to have different target behaviors that are impacting their quality of life. They don't all look alike underneath that. They don't all need to do trauma work necessarily. They don't all right. Some of them are med stables.

Helen Sneed: Them aren't right.

Speaker A: It's like there is to me, you want to base it on getting the right behavioral targets and the right mood symptoms that are really impacting that person And I think that when the treatment is geared towards that agreed upon hierarchy, that we really make progress as opposed to the treatment targeting diagnoses. So with that being said, though, yes, it was, you know, it made my heart very happy when it became more recognized. I feel like I already knew that from the beginning, but they, you know, we have to wait for it to catch up in terms of it being transdiagnostic, in terms of working with, you know, folks with, you know, mood disorders, with, you know, bipolar disorder and, you know, PTSD and anxiety disorders and all the things. Right. Because again, my patients already came with multiple diagnoses and I just, I feel like we have to target those. Right. Behavioral target. So that really helps because the first thing we want to do is help give, give some relief to the patient, please.

Helen Sneed: Yes, it's nice to have that as a priority. You know, yes, I'm very practical. I'm curious. You know, we always try to, I mean, our podcast is for beyond people who have illnesses, but people who support them, who love them, who help care for them. What suggestions do you have for families, family and friends who are supporting a loved one who's in treatment with

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Helen Sneed: with dbt?

Speaker A: Yes. So I work with a lot of families. So I work with a lot of families who, my. My outpatient group practice, they work, are working with the teens or working with young adults who are not launching. I work with a lot of families doing family sessions too. And so when I'm working with the families, the first thing I want to do is, is help level the playing field. So I want to help the family members each to identify their own target behaviors that are impacting the interactions with their family member. I want to help, of course, increase their understanding of what their family member is struggling with and so that they can really increase both empathy and validation for what is real. Right. Because sometimes they may think the family member is just manipulating the family member is just being dramatic. And so really trying to help increase their understanding and awareness of how real their family members suffering is.

Helen Sneed: Okay.

Speaker A: And that that family member, though, is still responsible for their behaviors. Okay. They are still responsible for their behaviors, but that the family has all their own behaviors as well. And that I really want to help my. The patient to kind of get out of that identified patient role. I really want to help everybody in the family to identify a target that they're working for treatment that kind of plays a role in the interactions that, you know, that continue to possibly reinforce some of the problems that are breaking down the system or isolating my Patient. Right. So I really don't want the patient to be isolated from their family. And you know, again, my patient might be engaging in a lot of push away behaviors with their family too. Right. So my goal is to help the family, the system to move towards sensitive synthesis.

Valerie Milburn: That's a great goal.

Valerie Milburn: And although I hate to come to the last question because this has been just so interesting and I've learned so much, because the name of our podcast is Mental Health Hope and Recovery, we always wrap up with a question that is focused on hope. And given the scope of your expertise, what about DBT gives you hope for individuals fighting mental illness today?

Speaker A: It gives me so much hope. I don't, I don't think I always tell my patients when they're like, am I just going to be the worst patient you've ever. No, I said, I don't think there's no way I could have been doing this for the last 30 years, but 20 years, just DBT, that I could be doing this if I didn't have hope. Because I have seen with my own eyes at this juncture of my career, we have patients who lived in and out of the hospital or who had so many suicide attempts who are now, you know, they built their life worth living. And that doesn't mean without any pain, that doesn't mean without things happening. It just means that the ability to, to be able to gain the belief and the skills in themselves that they can move through something painful without having to think about destroying themselves. And that is, is the, that is the gist of it. It's not, it's to help them feel like they can be in what we would call normal misery without needing to move into self destruction. Right. That is, And I've seen it, I've absolutely seen that happen. And I believe in that. It could happen for anyone because so many of my patients, at least 75% have come from, from you know, really painful, traumatic backgrounds. And you know, so I think that, yeah, they, people are resilient in that sense. Right. I really believe in my patient's ability to save themselves.

Helen Sneed: Well, that, it, I, I just have to chime in yet again, that is exactly what happened to me. Is it gave me the, the ability to save my, myself.

Speaker A: Yes, yes.

Helen Sneed: And keeping me forward, you know, that.

Speaker A: Is what the best work is. Right. That is, is that happening?

Helen Sneed: Well, Penny, I wish we could talk for hours, but we can't hold you captive when so many people rely on you. They're going to come get us, so thank you. This has just been an invaluable education and enlightenment about DB and you. I. I want to make you aware of the fact that you have helped many, many of our listeners today.

Speaker A: Oh, thank you.

Helen Sneed: And. And I just. I want to thank you and we'll find a way to have you back and. And go into more of this because I. I find it of endless fascination.

Speaker A: Absolutely.

Valerie Milburn: Yes.

Speaker A: Well, thank you guys for having me. I got to do my own practice today. My own opposite action practice. I was so nervous about coming on.

Helen Sneed: It comes in handy, that opposite action. Well, and

00:50:00

Helen Sneed: now, speaking of sort of opposite action, Valerie will lead us in a mindfulness exercise, one of the key skills of dbt.

Valerie Milburn: Yes, I will. I love closing our episodes like this. What is mindfulness? I always give a definition. Mindfulness is a mental state achieved by focusing one's awareness on the present, present moment while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations without judgment. And today's mindfulness exercise focuses on the DBT skill of guess what? Opposite action seems appropriate. We're going to focus mindfully on how emotions require thought before we act. Emotions require thought before we act, and we can be mindful of those thoughts. Opposite action in relation to our thought works like this. If we want an emotion to stick around or increase, then we continue to engage in the action that supports that emotion. If we want an emotion to go away or become less uncomfortable, then we do the opposite of action that supports the emotion motion.

Valerie Milburn: It will get clearer.

Valerie Milburn: Let's try it. Let's get mindful.

Valerie Milburn: If you are driving or walking, please adapt this mindfulness exercise in such a way that it works in your current surroundings. If you can find a comfortable seated position, try closing your eyes if it's safe to do so. But settle in and breathe as always. Let's begin with a few diaphragmatic breaths. Whether your eyes are open or closed, let's steady our breathing with two diaphragmatic breaths. When you do this on your own, take as many breaths as you need to become calm and centered. I usually take 10 diaphragmatic breaths to begin my mindfulness and meditation practice. Let's breathe. Breathe. Inhale through your nose, expanding an imaginary balloon in your stomach. As you inhale. Exhale through your mouth, pulling your stomach in as you do. Inhale through your nose, expanding that balloon in your stomach. Drop your shoulders. Exhale through your mouth. Pull your stomach all the way in. Keep this slow, steady breath going. If you can bring to mind a time when you felt yourself becoming angry or you were angry, Did you say something negative to another person. Perhaps a you are or a you did statement. Or did you defend your stance or your action? Now really visualize this situation. Situation. Consider these possible opposite actions to anger, to show kindness or concern, or to walk away. In a mindful moment in that situation. Visualize showing kindness or concern or walking away. Now, if you can bring to mind a time when you felt yourself becoming depressed or were depressed, Did you become inactive or avoid contact with others? Now really visualize that situation. Consider this possible opposite action to depression. Become active. In a mindful moment in that situation, visualize becoming active.

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Valerie Milburn: If your eyes are closed, please open them and gently bring yourself back to the room.

Valerie Milburn: Thank you for doing this mindfulness exercise with me.

Helen Sneed: Well, thank you for more great moments of mindfulness, Valerie. It's always just such a pleasure. And you know, this is one of my favorite skills that we've just gone over to our wonderful listeners around the globe. Globe the year is drawing to a close and Valerie and I want to pause to acknowledge how much you mean to us. Without your presence and commitment to our podcast, we'd be lost. Our greatest goal is to reach as many people as possible who need the information we have to offer, and we are constantly impressed and grateful for your intelligent, passionate dedication. Dedication to learning everything you can about mental health and the roads to achieving it. As we face the new Year, Valerie and I send our warmest wishes for the challenges and victories that lie ahead and our deepest hope for your progress on the road to recovery.

Valerie Milburn: Indeed. Thank you to all our listeners around the world. You are the reason we do this work and we have a year of great episodes ahead for you. You know, our mental health affects every aspect of our lives and how we live our lives affects our mental health. And this offers so many mental health topics for us to explore here on Mental Health, Hope and Recovery. Join us as we delve into these subjects that affect our well being, bring you guest experts and personal stories of recovery. And as always, always focus on the.

Valerie Milburn: Hope and recovery inherent even in the.

Valerie Milburn: Depth of mental health struggles. And thank you Helen for another year getting to produce this podcast with you. The work we do fills me with purpose and joy and fuels my own recovery and well being. So here's to 2026. A great year for you, for me, for our listeners, and for the Mental Health, Hope and Recovery Podcast cast.

Helen Sneed: And now I leave you with our favorite word. Onward.

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