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

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.

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We discuss:

• The basics of dialectical behavior therapy (DBT) and how it differs from cognitive behavioral therapy (CBT) [3:00];
• Treating depression with CBT: history, effectiveness, and how it laid the groundwork for DBT [8:15];
• Marsha Linehan’s inspiration for developing DBT [16:00];
• Explaining borderline personality disorder (and associated conditions) through the lens of DBT [20:00];
• How work with suicidal patients led to the development of DBT—a dialectic between change and acceptance [35:30]; 
• Details of DBT: defining the term “dialectical” and how to access the “wise mind” [44:30];
• Practicing mindfulness and radical acceptance in the context of DBT [51:00];
• Applying “radical acceptance” to tragic scenarios [1:02:00];
• The five domains of skills taught in DBT [1:07:15];
• Why Marsha chose borderline personality disorder as her focus when developing DBT [1:13:30];
• Is there any benefit in doing DBT for someone without a pathological condition? [1:15:45];
• The DEAR MAN skill of DBT [1:20:00];
• Adapting DBT skills for adolescents and families [1:31:00];
• Identifying vulnerability factors, increasing distress tolerance, and the impact of physical pain [1:33:45];
• The DBT chain analysis: assessing problem behaviors and identifying vulnerability factors [1:44:30];
• Why the regulation of emotions can be so challenging [1:50:30];
• The importance of mindfulness skills in DBT [1:53:30];
• Opposite action: an emotion regulation skill [1:57:00];
• Advice for those wanting to explore DBT [2:03:15];
• Finding a well-trained DBT therapist [2:08:15]; and
• More.

The basics of dialectical behavior therapy (DBT) and how it differs from cognitive behavioral therapy (CBT) [3:00]

If Shireen was at a party and somebody asked her “What is DBT”, what would she say? 

•  DBT stands for dialectical behavior therapy
• It’s a form of talk therapy that is largely inspired by cognitive behavioral therapy (CBT)
• We often say that DBT is a form of cognitive behavioral therapy that was designed for individuals that have complex mental health problems
  • It was originally designed for individuals that are suicidal or self-harming, and who may meet criteria for a disorder called Borderline Personality Disorder
• At its simplest,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 beyond that

How is cognitive behavioral therapy (CBT) different from dialectical behavior therapy (DBT)? 

• CBT is a class of talk therapy with features that distinguish it from other forms of talk therapy
  • CBT is present and focused on what is happening for people right now
  • Focused on what the patient is experiencing
  • Less focused on the patient’s history, childhood
  • Less focused on things that led to the problems the patient is experiencing
  • CBT is present-focused
  • CBT is focused on working with thoughts and behaviors  that go along with the problems that people experience
• In CBT-I the focus is on thoughts that contribute to insomnia
  • How can these be modified or changed to increase the likelihood of falling asleep or staying 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?
  • At its most concrete level, it is working with thoughts and behaviors that in the present are contributing to your problems right now
  • So, it’s very much an active problem-solving approach 
• People may have the idea from watching TV/movies that the best therapy is one where you go in and talk about whatever is on your mind
  • CBT and DBT are more structured and guided than that
• CBT and DBT are evidence-based
  • Treatments are constructed in a way to allow their effectiveness to be measured
  • If something is found to not be effective, then it’s not likely to remain in the therapy
  • The goal is to be as empirical and scientific as possible

How long has CBT been around as a discipline? 

• Aaron Beck is the figure associated with the beginning of CBT
  • He died last year, at age of 100
  • He was in his 60s when he 1st started developing his form of cognitive therapy
  • Hew was trained as a psychoanalyst and found it wasn’t that useful for a lot of patients

This prompted him to develop an approach that was more focused on changing the way people thought about themselves and others 

Treating depression with CBT: history, effectiveness, and how it laid the groundwork for DBT [8:15]

Marsha Linehan is the creator/ founder of DBT

• Originally Marsha set out to apply what might be considered standard CBT to folks who were chronically suicidal
• Perhaps beginning in the ’70s, 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
  • In the ’70s, ’80s, it was really the heyday of behaviorism 
    • The idea was in many ways oversimplified

The idea was that we could treat any mental health problem with behavior therapy in very few sessions, just by applying these standard principles of what we know about behavior change

• Behavior therapy and CBT was mostly focused on treating anxiety disorders in those days
  • The idea was that you could have somebody who came into treatment with a fear of something (i.e., 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
  • The behavioral therapy approach to this (or the CBT approach to this) would be to teach people competing thoughts 
    • So, rather than thinking, “this thing will kill me”, I can learn to have thoughts like, “I can tolerate this”
    • This might be difficult, but I can handle it
    • This is not going to kill me
  • But those thoughts were only one part of it
  • The other piece of it was the more behavioral piece, which is 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 is actually going to be coming into contact with spiders repeatedly over and over again, so that you learn that you can handle it
    • But you also learn that the feared outcome is not going to occur

Peter’s summary of CBT: change your thoughts, and get exposure  

CBT (cognitive behavioral therapy) for phobias and depression

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Shireen Rizvi, Ph.D., ABPP

Shireen Rizvi, Ph.D., ABPP, received her doctorate in clinical psychology from the University of Washington where she studied borderline personality disorder and Dialectical Behavior Therapy for more than five years under the mentorship of Dr. Marsha Linehan. She completed her predoctoral clinical internship at the Boston Consortium in Clinical Psychology and a NIMH postdoctoral fellowship at the National Center for PTSD at the Boston VA Healthcare System. Following this fellowship, she was Assistant Professor of Psychology at the New School for Social Research in NewYork City from 2006-2009 before coming to the Graduate School of Applied and Professional Psychology (GSAPP) at Rutgers University in 2009.

Shireen is board certified in Behavioral and Cognitive Psychology and in Dialectical Behavior Therapy.  She is the director of the Dialectical Behavior Therapy Program at Rutgers University.  Shireen is a Professor of Clinical Psychology at the GSAPP at Rutgers University, where she also holds affiliate appointments in the psychology department, School of Public Health, and the Department of Psychiatry. Dr. Rizvi serves as a primary mentor for students in both the Psy.D. and Ph.D. programs.  In 2017, She was presented with the “Spotlight on a Mentor” award from the Association for Behavioral and Cognitive Therapies (ABCT).

Shireen’s research interests include improving outcomes, training, and dissemination of Dialectical Behavior Therapy (DBT) for the treatment of complex and severe populations. Dr. Rizvi has received funding from the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), Rutgers University, and the American Foundation for Suicide Prevention (AFSP) for her research. Her work has resulted in over 70 peer-reviewed articles and book chapters, as well as a sole-authored book entitled Chain Analysis in Dialectical Behavior Therapy and a co-edited volume, DBT in Clinical Practice (2nd edition). [Shireen Rizvi, ABPP and DBT-RU Staff]

Twitter: @DrShireenRizvi