[SPEAKER_01]: And just between us, say it.

[SPEAKER_04]: Just between us, say it.

[SPEAKER_04]: Hello, I'm Allison Raskin.

[SPEAKER_04]: I'm a writer, relationship coach, and I'm officially a brunette again, baby.

[SPEAKER_02]: Hey, I'm Gabe Dunn.

[SPEAKER_02]: I'm a writer, by Con, by sexual icon, wink, and I have a little tattoo of lemons.

[SPEAKER_04]: Oh yeah, you do.

[SPEAKER_02]: How's that?

[SPEAKER_02]: It's good.

[SPEAKER_02]: My friend found out that she had, did you know there's such a thing as stage zero breast cancer?

[SPEAKER_02]: No, I did not.

[SPEAKER_02]: Yeah, she had stage zero.

[SPEAKER_04]: What does that mean?

[SPEAKER_02]: Um, I don't know, 100% know.

[SPEAKER_02]: I think it's like just kind of the earliest one you can have.

[SPEAKER_02]: And they found her like kind of colleges was just doing a check and found it.

[SPEAKER_02]: And then she was worried she needed a radiation, but before we found out that she doesn't, we went, she asked if we could go get little lemon tattoos, because life gave us lemons.

[SPEAKER_02]: And so she got one, because of that, and then I got one on the num part of my leg.

[SPEAKER_04]: Oh, that's so smart.

[SPEAKER_04]: So it did hurt at all.

[SPEAKER_02]: No, and I was like, this is, this is good because it's like this is where all the the chronic pain and all of that started so I've got it right on the little area that went numb first.

[SPEAKER_02]: Wow.

[SPEAKER_02]: That's where the lemon started.

[SPEAKER_04]: But honestly, talk about taking lemons and making it to lemonade, you've got a pain list tattoo.

[SPEAKER_02]: Exactly.

[SPEAKER_02]: Which I've always thought would be the case.

[SPEAKER_02]: And now she doesn't need radiation.

[SPEAKER_02]: So what do you do for it?

[SPEAKER_02]: I think just like men's.

[SPEAKER_02]: I don't actually know but she doesn't need oh they maybe did like a biopsy and took some stuff out I think but yes, she she and ended up that she didn't need radiation.

[SPEAKER_02]: So I think the lemon tattoos did it Wow We should not spread that kind of misinformation Yeah, get a tattoo of lemons and everything wrong with your body will be fine.

[SPEAKER_02]: RFK Junior said so [SPEAKER_04]: Well, this is just between us, a variety show filled with heartfelt advice.

[SPEAKER_02]: Ridiculous games and brutal honesty.

[SPEAKER_04]: This week, we're going to be talking about bottom surgery because Gabe wrote a really interesting and insightful piece about like his feelings around bottom surgery.

[SPEAKER_04]: And I thought, what the hell, let's turn that into a topic.

[SPEAKER_04]: So we can talk about it more.

[SPEAKER_04]: Oh, thanks.

[SPEAKER_02]: Up next, we've gotten exciting interview with our highly esteemed guests.

[SPEAKER_04]: Welcome back to Just Between Us.

[SPEAKER_04]: It's time for the juiciest most scandalous most controversial segment known to all of podcasting.

[SPEAKER_02]: Top questions.

[SPEAKER_02]: This week on the show, we have Dr.

Shireen Rizvi and Dr.

Jesse Finkelstein, who are co-authors of real skills for real life.

[SPEAKER_02]: Dr.

Rizvi is a licensed clinical psychologist with more than 20 years of experience and dozens of peer-reviewed publications on DBT suicide and mental health.

[SPEAKER_02]: Dr.

Frinklestein is a clinical psychologist, educator, and creator of Innovative DBT-based interventions.

[SPEAKER_02]: Hello.

[SPEAKER_02]: Hi.

[SPEAKER_01]: Hi.

[SPEAKER_02]: One holiday season.

[SPEAKER_02]: My mom bought me a book called DBT for Dummies, and I'm just wondering how much of a read that was.

[SPEAKER_02]: Was that rude of her to do?

[SPEAKER_01]: Ha ha ha.

[SPEAKER_01]: What's your relationship like with her now?

[SPEAKER_02]: Sure, I'd say mixed.

[SPEAKER_01]: OK, then possibly?

[SPEAKER_00]: Well, I think DBT is a great gift for anyone.

[SPEAKER_02]: And that's the spin, and that's the spin we're looking for.

[SPEAKER_04]: Yeah.

[SPEAKER_04]: I would love to get into the history of DBT because it is an interesting origin story of how it was created.

[SPEAKER_00]: Yes, so Dbt was created by Marshall in a hand, who was my mentor at the University of Washington, that's where she spent the majority, that's majority of her career was at the University of Washington.

[SPEAKER_00]: She developed Dbt while she was interested in working with a population that she would sometimes refer to as the worst of the worst, meaning a group of people that nobody else wanted to treat.

[SPEAKER_00]: and that population was people who met criteria for borderline personality disorder and who were chronically suicidal and self injuring.

[SPEAKER_00]: So DBT was developed to treat that population years later, I don't know if this is what you're referring to Ellison, but years later she kind of came out with her own story that was published in the New York Times and then in her own memoir, [SPEAKER_00]: that talked about her own personal struggles with suicidality and self-harm and how those experiences led her to develop some of the fundamental ideas in DBT.

[SPEAKER_00]: What is it stand for?

[SPEAKER_01]: Dialectical behavior therapy.

[SPEAKER_01]: It sounds very fancy.

[SPEAKER_01]: It is fancy, right?

[SPEAKER_01]: It's a fancy.

[SPEAKER_01]: just for transparency sake, Shireen was my teacher and was the person who introduced me to DBT.

[SPEAKER_01]: So, um, I am experiencing some measure of anxiety talking about it in front of her, knowing that, you know, she's wouldn't be assessing me at the end of this podcast.

[SPEAKER_02]: Well, you already wrote a book together.

[SPEAKER_02]: I was going to say you already won.

[SPEAKER_02]: You already did it.

[SPEAKER_01]: The chick is up.

[SPEAKER_02]: The jig is up, she can't back away, even if she wants to.

[SPEAKER_00]: And it's so true.

[SPEAKER_00]: Yeah.

[SPEAKER_01]: So Shireen, how would you define DBT?

[SPEAKER_01]: For her, or the Thai lecdic?

[SPEAKER_00]: Yeah, well, just going back to kind of that origin story, when Marcia first started to treat this population, she wanted to take what she considered to be standard cognitive behavioral therapy or CBT to the population.

[SPEAKER_00]: And she tried her best, but was actually faced with some problems pretty quickly, because CBT is very focused on change, like [SPEAKER_00]: You have all these problem behaviors, let's figure out how to not do those problem behaviors anymore.

[SPEAKER_00]: You have these unhelpful thoughts, let's figure out how to think something different instead.

[SPEAKER_00]: And when she tried to take this approach of, let's change all those things, it was met with a lot of pushback.

[SPEAKER_00]: And basically the pushback was, if I could have changed [SPEAKER_00]: my problems and my thoughts.

[SPEAKER_00]: I would have done so a long time ago.

[SPEAKER_00]: You clearly don't understand how painful, difficult, challenging all of my issues are if you think it would be so easy to change.

[SPEAKER_00]: Right.

[SPEAKER_00]: Oh.

[SPEAKER_00]: So she started to [SPEAKER_00]: Iterate, you know, the treatment, so that it wasn't just CBT anymore, she started adding in some other components, and those components that she added in were first, the concept of acceptance, how do you actually accept yourself, your life, your situation, exactly as it is, actually without trying to change it, how can you do that and by doing that, can you reduce your suffering?

[SPEAKER_00]: So she introduced that and that was met with by the people she was trying to sound on with some positivity, but then the response was, you don't get it.

[SPEAKER_00]: If you can't possibly expect me to just accept things as they are when my life is so miserable and I'm engaging in all these problem behaviors and people hate me and all these things like, how can I accept all that?

[SPEAKER_00]: So that's where the addition of the concept of dialectics came in, which is how do we dialectically take these two seemingly opposites, change and acceptance, and put them together and actually hold them together at the same time that everything is perfect as it is and [SPEAKER_00]: it needs to be different, right?

[SPEAKER_00]: You are perfect as you are and you need to change.

[SPEAKER_00]: These elements came into the treatment and that's where the idea of a dialectical approach was born.

[SPEAKER_03]: We're going to take a quick break, but stick around.

[SPEAKER_02]: And we're back.

[SPEAKER_02]: You mentioned that it was like everybody hates me.

[SPEAKER_02]: Is it like a mix of, you know what?

[SPEAKER_02]: This is what I'm like and maybe it'll just be harder for me to find friends or people who want to be around me.

[SPEAKER_02]: Is it like the self-awareness is the first part, you know?

[SPEAKER_02]: Yeah, it's sort of like hard to accept and then be kind to yourself and then also be really truthful with yourself about what you're like.

[SPEAKER_01]: I think that anything you're looking to change is really hard.

[SPEAKER_01]: If you're not fully accepting of the thing that you're trying to change.

[SPEAKER_02]: That makes sense, yeah.

[SPEAKER_01]: I'm trying to think of a good metaphor here of changing something that you're not aware of.

[SPEAKER_01]: I don't know, it's like if you recognize that climate change is an issue, then pretending that it's not happening is not going to make you any more effective at changing it.

[SPEAKER_01]: And the same goes with our interpersonal relationships with anything that we suffer with.

[SPEAKER_01]: And what I really like to also, which I think is helpful, is a lot of the acceptance comes with a heavy dose of self-compassion.

[SPEAKER_01]: It's hard to accept when we don't feel kindness for ourselves.

[SPEAKER_02]: Yeah.

[SPEAKER_04]: My understanding of DBT also is that it's a lot around distress tolerance, right, that there's like these really big emotions that people feel.

[SPEAKER_04]: And so what are some practical [SPEAKER_04]: behaviors and steps that we can take to regulate, right?

[SPEAKER_04]: Like this is sort of like where putting your face in ice water comes out of and these sort of like behavioral adaptations and changes to sort of like bring you back to yourself.

[SPEAKER_04]: Can you talk a little bit about how that folds into all of the greater philosophy?

[SPEAKER_00]: So one of the primary components of the package of DBT treatment is what we refer to as the skills training piece.

[SPEAKER_00]: And the skills training is teaching people in the therapy skills that we presume they don't know or never really learned, never really figured out how to do effectively.

[SPEAKER_00]: And those skills are divided into different categories.

[SPEAKER_00]: Those categories include mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distressed tolerance skills, which is what you just refer to.

[SPEAKER_00]: In terms of how they relate to the broader idea is that actually, [SPEAKER_00]: The skills themselves incorporate both change and acceptance.

[SPEAKER_00]: So the distressed tolerance skills are about how do you get through difficult moments without doing anything to make the situation worse, right?

[SPEAKER_00]: Without engaging in impulsive behavior or lashing out at somebody or quitting or whatever it is.

[SPEAKER_00]: How did it get through the difficult moment without doing anything to make the situation worse?

[SPEAKER_00]: Is it different than saying how do you change the problem, right?

[SPEAKER_00]: That caused the emotion in the first place.

[SPEAKER_00]: We have other skills to help you with that.

[SPEAKER_00]: So as a person going through DBT or as a person learning the skills, one of the things that you start to learn is what skill is most needed for this situation, what skill will make me the most effective in this moment.

[SPEAKER_02]: And what are some of those Allison said, dunking your head in ice water?

[SPEAKER_01]: Yeah, so that's a fairly fun one, I guess.

[SPEAKER_01]: Basically, there are these set of skills called the tip skills.

[SPEAKER_01]: And they're about very quickly bringing down the physiological arousal that folks feel when they are just at like a zero out of ten, at like a eight nine or ten.

[SPEAKER_01]: Um, like, so one is to being the temperature.

[SPEAKER_01]: It sort of activates the mammalian dive reflex by holding your breath, putting your face in some cold water, bending over at 90 degrees.

[SPEAKER_01]: I should qualify, speak to a medical provider if you have a heart condition.

[SPEAKER_01]: And it brings down the blood pressure because it forces all the blood to go towards your major organs in order to protect yourself.

[SPEAKER_01]: In so doing, it chills you out a little bit very quickly.

[SPEAKER_01]: There are other things that like a perfect example of this actually happened to me recently where I was on the subway, I live in Brooklyn, New York, I was heading into the city for a session and inevitably like someone pressed the emergency break and we were all stuck in a station for however long.

[SPEAKER_01]: And like increasingly, as it was getting closer to this session, I could feel just like physiologically, like my heart beating just the intensity going up.

[SPEAKER_01]: Now in those moments, like I was losing my, like I was gonna like, I don't know, break open the door and jump, like I was just like, what the fuck do I do?

[SPEAKER_01]: I can curse, right?

[SPEAKER_01]: Yeah, yeah, yeah, yeah.

[SPEAKER_01]: My urgent moment was just to sort of rumenate and sort of spin out, and instead I did pay breathing, which is essentially a skill where you extend your exhale a bit longer than your inhale, and in so doing it brought my emotional temperature, the physiological temperature down, and then I was sort of a bit more willing to practice other skills to tolerate what was something I couldn't solve.

[SPEAKER_04]: Yeah, I mean, I think, you know, I work with clients as a relationship coach and, you know, one of the really tricky things is like, what am I when I'm so activated?

[SPEAKER_04]: What do I do?

[SPEAKER_04]: And [SPEAKER_04]: It's really tricky to think yourself out of activation, right?

[SPEAKER_04]: It can be much more useful to actually turn to your body and a somatic treatment.

[SPEAKER_04]: Like, I'll be like, honestly, like, if you can like dance, could you do some high knees?

[SPEAKER_04]: Can you bring yourself into a different physical environment?

[SPEAKER_04]: And I think that one of the things that's really nice about DBT is like, it does really incorporate the somatic element.

[SPEAKER_04]: that I think a lot of people find missing in CBT.

[SPEAKER_00]: Yeah, I mean, we actually say the tipscills are for when you can't even think straight, that's how distressed you are.

[SPEAKER_00]: And when you can't think straight, that's not the time to pull out a worksheet or think about something logically.

[SPEAKER_00]: It's a time to, you know.

[SPEAKER_00]: Regulate just enough so that you could then think about something else you can do.

[SPEAKER_00]: So what you just said else it would be part of the tip skills that would be the intense exercise piece, like do something, activate, you know, get your heart rate up and then see how after a few minutes of high knees, you can come down a little bit, you can maybe think more clearly and then you could figure out something else to do.

[SPEAKER_02]: you do that in front of your partner or your parents.

[SPEAKER_02]: My, my, like parents start being insane.

[SPEAKER_02]: I'm just doing hi, knees.

[SPEAKER_01]: I mean, you know what?

[SPEAKER_01]: What are going to do?

[SPEAKER_01]: Yeah, let them, you know?

[SPEAKER_00]: We say do what works.

[SPEAKER_00]: Do what works.

[SPEAKER_00]: Do what works.

[SPEAKER_03]: We're going to take a quick break, but stick around.

[SPEAKER_02]: And we're back.

[SPEAKER_04]: I'd love to also talk a bit about the population that DBT was created for, because borderline personality disorder is something that is so stigmatized, even within the mental health community, right?

[SPEAKER_04]: You have all of these clinicians who refuse to even treat people with borderline, and then you also have people saying borderline isn't even a real thing, it is just reaction to trauma.

[SPEAKER_04]: And so, like, how do you, like, feel around the diagnosis and sort of the stigma that [SPEAKER_00]: I think that in some ways like the stigma has decreased slightly over time, it used to be even worse.

[SPEAKER_00]: And the ways in which it used to be worse was the ways in which therapists, psychologists, researchers talked about the disorder.

[SPEAKER_00]: So I've seen it referred to as the virus of psychiatry.

[SPEAKER_00]: I've seen it referred to with like all of the stigmatizing language in the description of the disorder.

[SPEAKER_00]: This was actually one of the things that I think Marshall Linahan really helped to advance was this nonjudgmental compassionate approach to people who meet criteria for BPD, which is why I think so many people find dialectical behavior therapy so attractive for them because it's finally the first treatment where they're not pathologized for every single thing that they do.

[SPEAKER_00]: So, I think stigma has changed a little bit, there's still a lot of stigma out there.

[SPEAKER_00]: So, to the first point, I will say, if therapists don't want to work with people with BPD, then that's not the therapist for you in some ways I feel like that's a self-selection process.

[SPEAKER_00]: I don't want to force anybody to work with BPD who doesn't want to work with BPD because they're not going to have the compassion and approach that we want them to have.

[SPEAKER_00]: So, so in that sense, I'm like, well, good for an incident to them.

[SPEAKER_00]: They don't need to treat BPD.

[SPEAKER_00]: The DSM obviously has a ton of [SPEAKER_00]: flaws and you know, different opinions about it.

[SPEAKER_00]: However, it has been a disorder that's been in the DSM since 1980.

[SPEAKER_00]: You know, there's been studies on the reliability of the diagnosis.

[SPEAKER_00]: I think to your point, Alison, about gender difference.

[SPEAKER_00]: What more recent studies have shown is that men and women both meet criteria for borderline personality disorder, but for men to get a diagnosis, they have to present as more severe.

[SPEAKER_00]: In other words, people who are making the diagnoses won't see it in men until it's really severe, but they'll be more sensitive to diagnosing it in women, which, you know, we can come [SPEAKER_01]: and else I want to speak to sort of the like how we conceptualize BPD and sort of what you were talking about in terms of trauma.

[SPEAKER_01]: One of the things that drew me when I was learning [SPEAKER_01]: It took a very transactional understanding of suffering.

[SPEAKER_01]: So I think historically, I often understood lots of pathology is sort of existing in the individual.

[SPEAKER_01]: Like I have anxiety, I have depression, I have BP, you know, all the, like it's sort of somehow inside of us.

[SPEAKER_01]: where is DBT at the understanding of BPD something we refer to as the bioscicial theory, which is essentially the idea that some folks are born with an emotional vulnerability.

[SPEAKER_01]: They may experience emotions more frequently, more intensely, and it takes them a longer time to come back to baseline.

[SPEAKER_01]: Now, when that emotional vulnerability transacts with an environment, [SPEAKER_01]: that invalidates their emotion, their experience, their thoughts or behaviors, that's where we begin to see real suffering.

[SPEAKER_01]: And that invalidation can look like so many different types of things, like trauma as a type of invalidation.

[SPEAKER_01]: invalidation culturally, socially.

[SPEAKER_01]: For me, what I find so powerful about DBT and sort of this conceptualization is that it really understands all our behavior is happening in transaction with one another, not just something that just sort of exists inside of us.

[SPEAKER_04]: But that comes with the difficulty of these personality disorder labels, right, because when you're given a personality disorder, there's this sense that it is core to you that it is unchanging and that you will have this for the rest of your life.

[SPEAKER_04]: Whereas if it is, oh, the symptoms that make you struggle that make it hard for you to regulate, to have these interpersonal relationships is a response to trauma, then there's sort of this feeling of like, oh, well, if I work through my trauma, then perhaps I can exist in the world in a different way.

[SPEAKER_04]: Uh-huh.

[SPEAKER_01]: So I, at one point, was invited to sort of do a AMA on a BPD Reddit, and I sort of declared, I mean, I guess, controversy, like, I don't believe in personality in general.

[SPEAKER_01]: Like, it's not, like, I believe like who we are is so contextual, like how I'm behaving with all of you, may look different.

[SPEAKER_01]: And yes, there might be traits and patterns over time, but I don't believe in a fixed [SPEAKER_01]: And so I do struggle with the idea of a personality disorder.

[SPEAKER_01]: It's like, how do you treat?

[SPEAKER_01]: Like, how do you, like, it sounds so intrinsic.

[SPEAKER_01]: I personally don't connect much with that label, but philosophically, and I don't know how helpful it is.

[SPEAKER_01]: And what I want to also recognize is that it was really interesting to hear from folks who had been diagnosed or reported to be so on that read it is that, [SPEAKER_01]: They also found, they're like, no, this label has been helpful for me to conceptualize my difficulties.

[SPEAKER_01]: So like, I want to recognize for some folks, it feels useful.

[SPEAKER_01]: I will say for me philosophically, it's just, I don't find it terribly helpful.

[SPEAKER_01]: And it's not sort of how I think about the world or others.

[SPEAKER_02]: Yeah, I guess if we can go back, what are the symptoms or what is borderline personality disorder?

[SPEAKER_00]: So there are nine different criteria in the DSM and for somebody to meet for borderline personality disorder, they have to have evidence of at least five of those.

[SPEAKER_00]: Okay, five of the nine.

[SPEAKER_00]: So some of the teaching points I always give about this is one is that because of the way the criteria are set up, there are 256 different ways to meet criteria for borderline [SPEAKER_00]: And because you just have to meet five of nine, you could have two people with borderline personality disorder and only overlap on one of the criteria, right?

[SPEAKER_00]: So it's incredibly heterogeneous as it is written in the so-called Bible of psychiatry.

[SPEAKER_00]: That said, and the way Marsha Linahan talks about it in DBT is actually to reconceptualize some of these criteria in a way that actually makes much more sense than to just say here are the nine random criteria of BPD.

[SPEAKER_00]: And so the DBT model of thinking about borderline personality disorder is first to say, what is core to the disorder is emotion dysregulation.

[SPEAKER_00]: having more intense, more frequent emotions and not knowing how to effectively control and manage your emotions when you have them.

[SPEAKER_00]: And if you see emotion just regulation is being core to the disorder, then all the other problems, [SPEAKER_00]: interpersonal problems, behavioral problems like impulsivity, et cetera, cognitive problems, all of that can be seen as directly related to emotion dysregulation.

[SPEAKER_00]: And in fact, if you look at the studies of those nine different criteria for borderline personality disorder, the one that is most commonly endorsed by people who meet the disorder, [SPEAKER_00]: is what's referred to as affective instability, which we could also say is emotion dysregulation.

[SPEAKER_00]: And among people who meet criteria for borderline personality disorder, over 90% will endorse that criteria.

[SPEAKER_00]: So that kind of lends some credence to this idea that emotion and emotion dysregulation is core to that.

[SPEAKER_02]: It's interesting because it's like, well, how do you know what's the right reaction to something?

[SPEAKER_02]: And is it just that it's causing [SPEAKER_01]: I mean, I would say it's, is it helping you move towards your goals?

[SPEAKER_01]: I think that's fundamentally the measure that we use.

[SPEAKER_01]: And it's another reason why I was personally so drawn to TBTs that me as a therapist, I'm not telling you how to live your life from my perspective.

[SPEAKER_01]: Um, it's, you know, I want to recognize that therapy there is power and trying like all those elements and I think DBT does it's best to present itself and work hard to be as non hierarchical as possible.

[SPEAKER_01]: And so fundamentally, the goal is to help the client achieve their goals.

[SPEAKER_01]: And we assess whether behavior is effective or not if it is helping them move towards those goals.

[SPEAKER_04]: If you want to hear the rest of this episode, and let me tell you, you do head over to patreon.com slash just between us.

[SPEAKER_04]: And for $3 a month, you can get access to all of our podcast episodes in full ad-free.

[SPEAKER_04]: Okay, that's it.

[SPEAKER_04]: Totality too.

[SPEAKER_04]: Totality too.