DBT 101: Learning How to Regulate Your Emotions

Margaret: [00:00:00] Mindfulness is not necessarily like meditation. It's not necessarily like kumbaya or being like totally detached as much as it is the psychological ability to create space and to change attention and awareness to different stimuli in your environment, including emotions or sensations or thoughts within your own body.

How to be patient. Welcome back to How to Be Patient. The podcast where I don't make any, where we fly 

Preston: solo, 

Margaret: actually untimely where we fly solo. Yeah. We have, we are producer lists this week. 'cause I had COVID and Embarrasingly in the big year of 2026. 

Preston: Mm-hmm. I, mean, who hasn't, who among us has not gotten COVID in 2026?

me 

Margaret: mostly, maybe, 

Preston: probably a lot of us actually. 

Margaret: I'm just like, I'm looking in the viewfinder right now and I like look so pale. Like I look like, I'm like impressed. My skin looks like actually white. [00:01:00] 

Preston: Yeah. it's like, 

Margaret: I think it's like a bad lighting thing, but I also think it's like I am truly this pale right now.

Preston: I mean, you kinda look ethereal. it's like all the, it's kind, the highlights are coming in. You know, she's, for those who are listening on audio, she's levitating actually too, while she's, the 

Margaret: leches have done their job. This, just kidding. This podcast is not support leches, in 

Preston: mm-hmm. 

Margaret: At least not 

Preston: COVID.

Stop listening. 

Margaret: Stop. This is an anti leach podcast, Preston. Today we are talking about DBT. but before we get into DBT, I have been inspired by you and Dr. Glaucomflecken Flecking and your. Your support of one another and finding humor in healthcare and in DBT we love to have some levity in the therapy.

And so I thought we might talk about as our opening instead of talking about DBT and where we need dysregulation, we might talk about people we've been finding funny lately online, especially in the healthcare space. And listeners. I did spring this on [00:02:00] Preston like two hours ago. so that's my bad. 

Preston: Hey, I consume funny content though.

It's easy. You know, it's like I just, it's just like going to the fridge. 

Margaret: I wanted to share these also because I feel like, I know we did the episode with Glaucomflecken PLN after you guys had your beef when you were like, Glaucomflecken. PLNs not funny anymore. Just kidding. But I will be clipping this part of the podcast from the page.

no, but talking about people that you guys both think are funny. and I just thought it would be fun to shout out some people who are like up and coming creators or like, just like. I feel like this week in particular, there's just been very good content I've been sending you that is like mm-hmm.

This person's like, these are some original people, so I have two to share. and I got permission from them to let me be able to play a bit of their tiktoks. Okay. So we are gonna roll the clip. We're gonna start with my first one, Preston, I don't know if you've seen Abby, but she's the one who talks about the girly swirly worley [00:03:00] on.

In healthcare, you've probably heard this sound, I'm gonna share one of hers. We are mutuals, which I find delightful. and if I can play the audio, I will. 

@abbiecantwell: No, you don't wanna go to work today. But if it's not you, then who's gonna serve evidence-based medicine all while looking Go sema. And the girlies deserve that and the patients deserve that.

So we gotta get to work. 

Margaret: I recognize this is like not the same thing you're gonna find on your stuff, but I like love Abby's. It's just like very much Dr. Divas in healthcare and like, I feel like being smart in healthcare and also being bubbly still is like, not if you're like bubbly as a woman in healthcare, sometimes it's like, oh, she doesn't know what she's talking about.

But it's like sometimes I wanna be bubbly and fun and a diva and. And someone has to do it. Also, serving evidence-based medicine. 

Preston: Someone has to be a Goma, 

Margaret: someone has to be Goma. So shout out to Abby. [00:04:00] I love her content and she talks about real things as well as an anesthesia resident, but also just as like, here's where you're gonna find me on call.

And like me and me on call knows luxury. and I feel like that is the way I cope with being on call sometimes too. So that's my first one. Do you have one you're gonna share with the class? Preston? 

Preston: That's good. Okay. I, was worried I was gonna copy you. but the, one I really like, this guy Amino, he's, is he your second?

Margaret: No. 

Preston: Okay. So Amino. I don't even know if I know his real name. I sent him an email, but he's this, I emailed Amino. I, his, he has like 13,000 followers. His profile is just like a picture of a cat. it's kind of like edgy meme type like, like Gen Z bio. But 

Margaret: mm-hmm. 

Preston: He did this series on essentially like practicing so that if I do residency in Atlanta or Montreal or something like this is how I would act.

[00:05:00] And so I guess he gives a little bit of a backstory in one of his talking head videos where he said he used to work in the music industry. He was like a producer, I think. And so he was around a lot of hip hop and was like going in outta the city. So, so it became very well versed in like kind of. The cultural vibe of different places.

So then he's like the whole concept as he comes in and he is like, fuck going on with it as he's like, like dabbing off the camera and saying like, don't worry man, we gonna take care of you. And, he is just funny. he has great comedic timing. His impressions are really good. I love his accents. And the videos were blowing up.

They were, you know, getting like a couple million I think, or at least, you know, like average of the series was probably like in the 600,000. So people were loving it and they're saying, you know, like, this is, culturally appropriate care. You know, this guy's like a, he's a medical anthropologist.

Like this is what real science is. And then we'll see if we can play some of them. but we may, might not be able to because he took them down. [00:06:00] So I think I went and checked his page today. All of his videos have been at least related to the, Residency skits have been taken down. And I feel like that was kind of just like staring in a mirror a little bit.

I guess. 

Margaret: I know I sent you, I was like, I was tagging like you and Glaucomflecken, like, I'm in those comments being like, it's the, father son and the Holy Ghost right now. 

Preston: God. Yeah, dude. It's just, it's, just a story that repeats itself. So someone felt that they were offensive and then they reported him to his school, and then his school was like, yeah, you're gonna take all these down.

And I, empathize with him because I'm sure he's probably like really excited to see all the, attention and how lively it's for people and they're celebrating this like, comedic thing that he created. Like it's, exhilarating. It's a wonderful feeling. And then you're also a powerless M1 who ultimately decides your career is more important than these like, fun videos you're posting, but it still hurts a lot.

So I feel for you man. We've been all been, there've been, or at least I've been there. I [00:07:00] dunno, 

Margaret: you've been there. 

Preston: How many of us have all been there? And I hope that, not a lot of us are there in that position. But I actually, I sent him an email, so if he wants to come on the podcast, he's always got an open invite here.

Margaret: Okay. I have one more. I think he's clocking in as of right now at like 1900 followers. So like, are we a tastemaker podcast now? Maybe? I don't know. No. this one's a little bit longer, but I just think it was like 20 good jokes, like within a span of 45 seconds and it reminded me Okay. Watching him and then also watching the one you just mentioned, it reminded me of when I first started following like you and Glaucomflecken Flockin and was like, now these are, some funny, creative people.

and so I feel like our listeners will enjoy this. See, this is why you guys should be watching the podcast. 

@dadiology: This glass is half empty. This glass is half full. This glass may be half full or half empty. Please correlate clinically. Period.[00:08:00] 

This glass doesn't exist anymore. This glass will return. Everyone will return. 

@abbiecantwell: Hey, sorry to wake you. Did you move today? 

@dadiology: Oh, I did med school in Boston, actually. you know the Longwood area. Ever heard of mess? Jeff, anything else I can do to help today? Glasses unchanged. Medicine to manage. Ortho signing off?

Probably not. This glass needs more fluids. This glass is fluid overloaded. How does one 15 March 2nd, 2049 Down to you. All right, let's run the list. List. What list?

Margaret: So I just think ology, wherever you are, early in the journey, I can't really pinpoint if he's in pharmacy or med school, but regardless, like, just like a rapid take. So, you know, when you were in your, beef with Glaucomflecken fleck and era, that was fake, but also you were talking about like repetitiveness in terms of content in the healthcare joke space.

Mm-hmm. I just feel like the like [00:09:00] different, doing different things, but like, just like breath of fresh air for all three of these. Yeah. Like they're doing things that are like creative and interesting and fun and bringing joy and doing the thing that I feel like you and Glaucomflecken fucking do really well.

Which is like not punching down. Mm-hmm. Like everyone gets to be in on the joke. 

Preston: I could tell he just had fun making that, which I think is like the content I resonate with. Like, I could see him laughing to himself as he comes up with the jokes and then like records it around the glass. and I think that's why everyone else thinks this is funny.

You know, like someone who's like genuinely trying to do something that they enjoy. They're not like pandering to an audience 'cause they haven't built up the audience yet. It's just, there's someone doing it for the love of the game. Mm-hmm. that's what makes me, me love it.

Margaret: So if you guys have other people that you think are funny and fresh and original, I don't know that we'll do this again, but we might, and like, I don't know, as I think it's really special to be able to take our platforms and like share with other [00:10:00] people who are doing cool things. We do that already, like when we have people on to talk about their research or their academic work or their other work online.

So like why not share the wealth and like where there can be joy and humor found in medicine, find it and share it with you guys. 

Preston: Mm-hmm. Yeah. Because, there are a lot of tired tropes, but there are fun people doing new things. 

Margaret: Yeah. Yeah. Okay. So now that we've, now that we've had our laughs, it's time to talk about emotion regulation and distress tolerance.

It's time to talk about DBT 1 0 1. and we will do that right when we get back from this break from our sponsors.

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Margaret: And sometimes you're looking for a pairing to really just settle in on your days off onto your couch with that cozy blanket, in which case Cozy Earth also has [00:11:00] very beautiful, very comfy matching set pajamas.

Preston: Yeah, and my first pajama set ever. So 2026 is off to a good start. The other thing is that there's a hundred night free sleep trial and a 10 year warranty on all their pajama sets, blankets, and any other product. It's one thing I really like about the company. 

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Margaret: So, we are doing a DBT 1 0 1 episode because we are lucky enough to have Dr. Kiki falling on with us in an e two episodes from now. She'll be on with us and she ha has written a book on DBT. She is an expert and instead of making her go over one-on-one information with us, we [00:12:00] wanted to save, we're gonna 

Preston: do now with you 

Margaret: exactly.

We wanted to save an episode of giving you the one-on-one so we could get into more nuanced takes that might take her expertise as a consult, and be able to take our understanding to the next level. And so today we'll be talking about DBT 1 0 1 and of course Preston, the question I'm gonna ask you, as I always ask, whenever we talk about therapies, what's your experience in residency or med school or just life so far in like interacting or practicing DBT, which is dialectical behavioral therapy for those listening at home?

Preston: So I. I think I've had probably two or three didactics lectures on DBT, with some practice. And then I have not like performed any like focused DBT myself. I refer a lot of my patients to like the DBT groups that we have in our clinic. So I think I'm familiar with it in theory. I know a couple of the worksheets that you can do.

I've [00:13:00] downloaded and printed off parts of the DBT workbook online. There's a whole PDF, so I know some sections of it, and that was about it. 

Margaret: Amazing. do you have to run any groups as part of your residency? 

Preston: No, all, of my therapy is individual. 

Margaret: Got it. 

Preston: Okay. Unless someone wants to bring their partner in.

And then I could be a couples therapist, 

Margaret: DBT couples therapy, honestly. I think that actually does exist. okay. My background is also not as an expert. I have no, I have never practiced DBT in the full fidelity model, which we'll get into what that means. I've been co, I've co-run groups over a couple years, but like nothing continuous, just like different kind of intro ones.

so we are not speaking as experts. I will say I had did teach the DBT intro like six lectures as part of my chief ship last year as like the therapy chief. So I feel good about leading you guys through this 1 0 1, but is why we'll have the expert on for more [00:14:00] 

Preston: because, 

Margaret: you're like 

Preston: a 2 0 1 or 3 0 1 level 

Margaret: I think.

Yeah, I think. Yeah. But, only a 2 0 1 or 3 0 1 level, which hoping to learn some more in child and maybe co-run some groups. 'cause like adolescent DBT is useful. So I think one thing that we should say is DBTs name dialectical behavioral therapy. Dialectical meaning Preston. Do you know this one? 

Preston: So like a dialectic is something that exists on two sides, or like, it's basically the concept of like nuance.

Margaret: Mm-hmm. 

Preston: Yeah. Yeah. in an academic discussion. 

Margaret: Yeah. So dialectical behavioral therapy comes from this idea. So Marshal Lenahan is a creator, of content Creator is the creator of DVT. And it's 

Preston: content in a way, 

Margaret: it's content, it's just different, it, life's content. she's the creator of DVT and Dialectical does, as Preston was saying, mean, kind of [00:15:00] two opposite things, belonging in one.

you'll often. In the sense of DBT, it's often holding kind of two truths or two stances together, even though they seem to be paradoxical or like they are opposites. it also can be seen in like the yin and yang symbol of like a little bit of everything. The opposite is in something and vice versa in DBT.

So do you have any idea how DBT came to be, Preston? And then I'll stop asking you questions off the top of your head, but I actually am curious 'cause 

Preston: you know, I think I saw a video of, Marsha, not that we're familiar, but she was talking about 

Margaret: she has passed away, so I 

Preston: Yeah, this was like from the, like nineties I think.

Margaret: Oh wow. Okay. 

Preston: Yeah, so it was an older video. I think she was just like talking about how it became necessary to find another way to get to patients with personality disorders because, supportive psychotherapy would ultimately going in circles, but then other like traditional [00:16:00] forms of therapy would, hit brick walls.

So I guess that was like her talking about like the need to start it, but I dunno too much about how she actually went about constructing it. 

Margaret: No, that's exactly right. And one of the things, so at the time, so this is I some like eighties ish nineties, DBT comes about in the time of psychoanalysis is still somewhat prevalent in the like, fifties, sixties, seventies, sort of eighties.

and then cognitive behavioral therapy or the, and the behaviorists were like really the big theme on the scene, especially for, psychologists and non-MD therapists because in the US MDs were the only ones who were practicing analysis at that time, despite what Freud wanted. But we'll get into that in a, separate episode.

So Marsh Lenahan. At the, for most of the history of DBT and the implementation, the story she told was what you were saying, which is like an academic one [00:17:00] and a true one, which is for patients specifically patients with borderline personality disorder, but other kind of severe emotion dysregulation or distress tolerance concerns, even outside of BPD, things like CBT would, they would maybe be kind of helpful but then get stuck, or there'd be a lot of distress and not be able to like, continue doing it.

Right. So like if you're self-harming or suicidal frequently, then it might impede what therapy can do, which is true also for psychoanalysis. But insight oriented or supportive wouldn't generate change at the pace or in maintaining safety in the way a more structured approach would work. that is the academic version.

That was what she talked about for most of her life. At the end of her life or in the last sort of five to 10 years, she actually became, had a, her own memoir come out, which is like. Her story, and about creating a life worth living, which people familiar with DBT will know as a phrase that is often part of that therapy, which is [00:18:00] that she actually herself had been hospitalized in her youth, and had lived the quote unquote emotional hell that she eventually created DBT four.

And that the kind of seeds of DBT actually came from her figuring out what worked for her, both within the different placements she'd been in, but also in just figuring out how to try to live her life despite really intense emotional, you know, emptiness, emotional dysregulation, and the desire to harm herself, which in academics and at her level, she did it more towards the end of her career.

But it's still huge for her to disclose that like. This therapy, especially when the diagnosis we're talking about is so stigmatized, which is, borderline personality disorder. For her to actually say, like, on me, this like big ac like hugely cited academic psychologist, I have this. And that's how this came is a big part of the story of how it came to be.

I think, I [00:19:00] mean, I would view it probably as hugely validating for a lot of the people that live under this diagnosis and have benefited from this treatment. 

Preston: Yeah. It's like a mic drop. 

Margaret: Mm-hmm. 

Preston: I, did this because I figured it out on my own. 

Margaret: Mm-hmm. 

Preston: You know, like I, I know this disorder better than anyone else.

Margaret: right. 

Preston: Yeah. even now, like, I think a lot of psychiatrists are hesitant to disclose their own mental illness. 

Margaret: Mm-hmm. 

Preston: even if it's been like. What informs you to become a better doctor? And if you look at the specialty breakdown, psychiatrists are more likely to have mental illness than other specialties.

Margaret: Mm-hmm. 

Preston: Probably why a lot of them are motivated to go into it in the first place. Yet we still feel that wall. 

Margaret: Yeah. Yeah. And I think like it, I definitely think you're right that it's like true in general. I think even more so it's true for things like addiction or for like borderline personality disorder or other personality disorders that do have carry so much stigma.

I mean, I know [00:20:00] people want, you guys want us to do a borderline personality disorder versus like complex PTSD and episodes along that we will, we're working on it. Consider this our first foray. I'm speaking to the fourth wall right now. We know that you want that. We're working on it. Yeah.

So yeah, it's just, it's the history of DBT is, interesting in that it has that unique founder story. I think, DBT is now used not just for borderline personality disorder. It's used for all sorts of people who may need help with emotional distress tolerance, and it's evidence-based for those populations.

It can be used in PTSD anxiety, we'll use it in eating disorder treatment. ultimately, I think it's somewhat trans diagnostic in terms of it can be helpful for a set of emotional and cognitive like skills and behaviors beyond just the personality disorder category of, borderline personality disorder 

Preston: and also I think just life skills.

Yeah. There, there's a section of it on like [00:21:00] interpersonal effectiveness that I've taken to my personal life. Like, I don't know. I have emotions like anyone else. I don't know if I have a disorder of regulating them yet. As I learn about DBT, I'm kinda like, oh. It's pretty good actually. I think, I'm gonna try this for myself.

we joke that I think DBT should just be kind of taught to every, everyone in elementary school. 

Margaret: Mm-hmm. 

Preston: As you're learning how to navigate math and reading and writing and drawing. Also how to interact with other people with actually good, regimented, curricula. 

Margaret: A little bit of wise mind just for everyone.

Yeah. I mean, I agree. which, that actually segues us nicely into talking about the four kind of main pools of skills or concepts within DBT, 

Preston: pillars, if you will. 

Margaret: Pillars. Before I say that, I wanna say a little bit about, I mentioned high Fidelity, DBT, So high Fidelity, DBT or as Marshall Lenahan would call it DBT, [00:22:00] is how DBT has been most studied and practiced.

Now there have been studies around things like just skills training one-on-one work that are effective, and we won't get into the details on that, but that when we were refer to DBT as an effective treatment for borderline personality disorder or like recurrent chronic suicidality or self harm, most of the time that core literature is referring to high fidelity.

DVT. 

Preston: Sorry, I just keep thinking about the bank fidelity. You know, you know how that like arenas, like Invesco Arena, it's like 

Margaret: mm-hmm. 

Preston: This is DBT brought to you by Fidelity, which is where my mind, I know the high fidelity DBT is good and it's not sponsored 

Margaret: by 

Preston: a bank C 

Margaret: sponsor sponsored podcast, DBT, big DBT is sponsoring us.

Preston: Ah, yeah. It's like Fidelity sponsored the trials, so now they have to say high fidelity DBT every time that, okay, sorry. side FARs over. This is the really good type of DBT that we do all the trials on, and it's not just the little pieces. 

Margaret: Yes. So do you, [00:23:00] so to throw this back to you, Preston, what is true DBT?

What is the, like the format, how is it supposed to be done? 

Preston: Okay, so it's supposed to be done by like the, same therapist in an indi individual or group environment where you're checking in consistently for, okay, I'm, gonna get the timeline wrong, but I'm gonna guess around like 12 weeks. It's like 12 to 16 weeks.

And then the other part of this is that as you're like, bought into this therapy, you have, essentially a therapist on call so that even when you leave the session and you're having trouble with emotional dysregulation, you're supposed to be practicing your skills and you can call the therapist in crisis to have them kind of walk you through what you're supposed to do or help like reinforce those skills both in and out of the session, which is very different from how it's, practiced in a lot of different, like even in hospital settings.

In my engineer year, someone was like, oh, this person has borderline traits. Let's print out this little worksheet and just like hand it to him on the way out the door. 'cause [00:24:00] DBTs evidence-based for borderline personality disorder and I'm, that might've helped that person, but you know, it's not the whole package.

Margaret: Yeah. So like if Marsha Lenahan as is like, if she's like the Michael Jordan of emotion regulation, it's she's like, okay, here's my Michael Jordan, I'm the greatest of all time plan to be really good at basketball for her. Be really good at emotion regulation and what we have. And she's like, and I've studied it and I've applied it and whatever, and it won us these championships.

Do it this way. And then we're like, what if instead We have them watch 30 minutes of a Bulls games from the nineties, will that do it? And it's like, bitch, no, she's Michael Jordan just told you what you needed to do. But then insurance is like, we don't wanna pay for all that. And so we're not winning the championships to make a horrible metaphor longer.

Preston: And genius is public domain now. Yeah. I guess what, I'm thinking about is we have all this research about how great running is. Like, you know, it turns out that like people on marathon training [00:25:00] plans have, you know, better physiques and better mental health and you know, like increased VO O2 max.

Mm-hmm. And it's because they run 40 miles a week and follow this exact training plan. And they, you know, do cool down. They focus on their nutrition. We're like, wow, I wanna help someone's mental health, so I'm gonna tell 'em to go for a 30 minute jog one time. 

Margaret: Nailed it, 

Preston: like right around the block. And then they come back and they're like, I'm tired.

And you're like, do you feel better? 

Margaret: Did it fix it? Is that crazy? And they're like, I think I have asthma. And you're like, right. Okay. Well. Your insurance doesn't cover an inhaler. so yes. No, I think that you're right. And to finish this extremely extended metaphor, it, it might be better than them doing no running at all, which I think is what we have to think about with, if we take this extended metaphor back to DBT, doing some form of DBT or doing some form of these skills, learning or practice outside the high fidelity model does help.

It's just not [00:26:00] full DBT, I guess is how we say it. Mm-hmm. Which I, and you know, I think towards the end of her career actually Lenihan knew that and knew that it was like not being practiced that way necessarily, but 

Preston: not true. DBT 

Margaret: it's not true db Well, it's not. Well, and if you think about it, it's like people in at true DBT.

So you were right in what you were saying, mostly like, it's like individual therapy with a DBT trained and certified like therapist. So who's actually done this model and then it's the. 24 7 available like DBT type of response coaching over the phone. And then there's like the group skills learning part that goes through all of that.

It's more than 12 weeks, usually it's like three to six months and then you like, oh wow, repeat it, whatever. and then there's the AKI. Part of it is the therapy, the therapist and coaches and the care team meeting very frequently and not like, oh, we'll talk to you on the phone every couple months. Like that meeting where they discharge sort of all of the affect and like what's going on with the patients that they're working with and [00:27:00] what's happening in group and individually and in the calls is the other core component of high fidelity DB dbt.

And I don't know if you've ever tried to get, can 

Preston: you explain that? The discharging effect? 

Margaret: Yeah. So I mean, I think one of the reasons that, one of the reasons that borderline personality disorder is stigmatized is because people struggling with borderline personality disorder by the definition of the disorder.

Are doing things that harm themselves or at least struggling with urges to harm themselves, suicidality, the emptiness, and then interpersonal instability. If you are struggling with interpersonal instability, that comes out in the therapy relationship as well. And that interpersonal instability is often things like impulsivity or taking out anger or irritability or no showing and all that stuff.

And so if you really want a therapist to be able to be with a patient who they're constantly, it's constant high acuity and constant interpersonal, [00:28:00] maybe like difficulties, friction, basically. Then if you don't want them, if you want you to actually treat clinicians like human and you don't want them to just take that out on the patients and do fucked up shit, basically like.

There has to be a place where we're recognizing what's happening in these relationships. Are we actually helping or are we getting sucked into some dynamic that is like not working and that you don't need to be an, analyst to think that it like can just be like a behavioral group dynamics. How is this all working?

Preston: I see. Okay. So, so this is this for the therapists to almost like release the pressure and 

Margaret: Yeah. 

Preston: Get their bearings again. Okay. Yeah, I can see that'd be, very helpful. I, you don't even think you need to be an expert to know that like things get messy really fast in those types of like high acuity relationships.

Margaret: Right? And like by definition, the personality sort of diagnosis that we're talking about with this is people who don't necessarily want to but are struggling with interpersonal, [00:29:00] like boundaries, self-care, sense of emptiness, hostility, impulsivity, and like reactions of like self-harm or suicide due to like interpersonal rejection.

So you can imagine, But that can be tough to hold alone. I mean, all of us have patients like this and it doesn't need to be borderline personality disorder, but I think all of us have had patient care situations where someone's really sick, they don't wanna be sick, but the way that they're sick maybe is complex because of how psychiatric illnesses make us sick.

And so I think of like first episode psychosis even, or like people who have like schizophrenia or bipolar that's not controlled. And like it's really hard as like a resident or attending, but it's really hard as a clinician to hold that really sick person by yourself and not be like worried all the time.

@abbiecantwell: Mm-hmm. 

Margaret: Or do weird things to try to like make yourself feel better or make them feel better and kind of crash out. And that's like, without even getting into like boundary work and like the evils that [00:30:00] psychiatry has done, it's just like human to human being. How do you help someone who's really sick?

Preston: Yeah, absolutely. Okay. So we're treating both the patients. Therapist because everyone involved is a human. And among the, I guess the academic parts of this, there are these four pillars that we're gonna get into. 

Margaret: Yeah, the other thing I just wanna say is like this splitting, like whenever we're talking, and that's like something that we like throw out there as a defense mechanism, but splitting is something that can happen again in the diagnosis as like a defense mechanism for a borderline personality disorder is splitting parts or the good part and the bad part.

And so that is also why like the team meetings and also being held by multiple clinicians is important so that there's less of a continual split that like this clinician is good. And this other clinician that I'm seeing who don't talk to each other in a non DBT model, one is holding all the good and one is holding all the bad.

And that's [00:31:00] pathological. 

Preston: Yeah. So, so for those who are listening that aren't familiar with the term splitting, it's in its essence the inability to engage with the dialectic. So it's hard to hold two truths about someone at the same time. So you know it like, it, it becomes very challenging for someone to say like, oh, I'm mad at you, but I still think you're a good person.

It's either you're the best person ever or you're terrible. And that is kind of the lens through people with personality disorders can see, the world in either like themselves and other people. 'cause it, they will split on themselves too, but that can lead to these like, challenging dynamics.

So that, that is core is why like dialectic is like introduced in the beginning of it 'cause it's tries to undo that splitting aspect of the personality disorder. 

Margaret: And then as we, so as we move into these four pillars, the last thing I'll say about dialectic and what Dr. Felling says in her book that like the core principle or therapist orientation is everyone's [00:32:00] trying their best and I need to do something differently or better.

But that is like the kind of. Paradox are two seemingly, you know, exclusive truths that we're holding and as the therapists work, and then trying to help the patient internalize when we're doing DBT. 

Preston: So the therapist starts with the assumption that all the patients are doing their best and if their improvement needs to be done, it's on my side.

The therapist. 

Margaret: Yeah. So the presumption is at the same time. So this is the dialectic. The presumption is that you are truly trying your best in doing the best you can, and we need to improve and do better and try differently. 

Preston: Okay. I see 

Margaret: that like both of those things are true and that even though they appear that they can't both be true at the same time is the dialectic.

Preston: Mm-hmm. I see. 

Margaret: So we'll take a quick break and then we will start by talking about mindfulness and emotion distress, tolerance, and then we'll do [00:33:00] the other two as well.

Okay, welcome back. Let's talk about the pillars. So we are now in our buckets of both concepts and skills. So the first one, that is often introduced in the group settings is mindfulness, which we know and love on this podcast, right? We love mindfulness here. I 

Preston: do it all the time. I just did it this morning.

Mindfully. 

Margaret: I'd be mindful, 

Preston: I don't mind 

Margaret: mindfulness for those who are interested in it. We've done episodes where we've talked about the concept of mindfulness psychologically, Early season one I think, but just as a refresher. Mm-hmm. Mindfulness is not necessarily like meditation. It's not necessarily like kumbaya or being like totally detached as much as it is the psychological ability to create space and to change attention and awareness to different stimuli in your environment, including emotions or sensations or thoughts within your own body.[00:34:00] 

And mindfulness is a core part of D-B-T-D-B-T also is kind of one of its roots for per lenahan is Zen Buddhism. and so it does actually carry from there as like part of the inspiration of how do we apply this and use it in a psychological framework we can study. often the thing that we're talking about with mindfulness and DBT are the what and the how skills, Preston, have you ever heard this?

I can never, I literally can never remember what these are or how to remember that one. 

Preston: no, I, can't think of the what and the how skills. 

Margaret: Okay. So I wrote them down. This is why, 'cause I always forget what they actually are 

Preston: like, like what am I feeling and, how is this coming to be? 

Margaret: So I feel sometimes the DVT that I can't remember this because they aren't actually totally unique concepts from one another, but that's just me being, it's my defense.

So it's 

Preston: hard to pin it down to DBT 

Margaret: mechanism. Yeah. Well, no, it's just like, so the what skills are observe, describe, and participate. [00:35:00] so they're like, what around mindfulness? So observe more closely like what you're doing in the exact present moment. Describe it with words to like, really focus your attention onto what is happening in the present moment, and then participate.

So like an example they give is like, don't try to multitask like while you're on a run. Like try to just notice the sensation of running the how skills are one minded, non-judgmental and skillfully. So I think I am, this is, I'm gonna get DVT hate for this, but I think I'm valid in feeling like these are not all really truly separate concepts.

Preston: Okay. Can we, explain the how skills a little bit more? what does one minded mean? Yeah. 

Margaret: So the how is like while you're doing the, what skills is the adverbs you're trying to sort of do it with? So one minded means, again, like if you're going for a run, you're not going for a run listening to a podcast and also trying to like, I don't know, take pictures and calculate your heart rate all at once.

So [00:36:00] one minded is like, the attention is only focused on one component of the experience. 

@abbiecantwell: Mm-hmm. 

Margaret: the non-judgmental, I think is distinct in that it's like, while you're doing it, you're trying to turn down this voice that's like narrating how you're doing it. So instead of like speaking into a podcast, Mike, and speaking, and also at the same time having the critical voice be like, you should intonate your voice differently and you should be doing this.

And like, oh, you're rambling and da turning that voice off would be the nonjudgmentally. 

Preston: Taking away the shoulds and the coulds and making them all is and ares, 

Margaret: yes. Yeah, exactly. 

Preston: Am doing this, but not I should be doing anything. 

Margaret: Mm-hmm. 

Preston: Mm-hmm. Okay. 

Margaret: And then the skillfully is like a core part of all of DBT, and I don't have a problem with the skillfully as part of the hows, which is just like, is this functioning?

Like, is this pragmatic towards what, I'm doing? 

@abbiecantwell: Mm-hmm. 

Margaret: And so it's hard for me to think of an example in terms [00:37:00] of like mind, like this specific part of being mindful, but like maybe if it's like you are trying to be mindful to how angry you are in traffic and it's just making you get more and more angry.

It's not particularly skillful to be mindful to that. 

Preston: I see. Okay. It's, paying attention to when you should focus on the alarm or not, I guess as you're describing these, like what and how skills, I'm thinking of like instruments in a cockpit, whereas. Maybe a lot of us can be, you know, we're flying and we know, knowing where to steer, but things like our altitude and our air speed and like the cabin pressure stuff, like our emotions, we may be less aware to aware of.

But then, you know, if the plane's crashing, I'm not gonna be like maybe focusing on certain things like the temperature in the bathroom right now or the, like, whatever else is happening. I, have a couple different, maybe monitors or instruments that I'm focusing on. 

Margaret: Mm-hmm. Yeah. [00:38:00] Yeah, The other part of, mindfulness is what DBT is often one of the common things that if you've probably heard of associated with DBT, which is Wise Mind, 

Preston: mm-hmm.

Margaret: You're nodding. How would you describe what Wise Mind is? 

Preston: So, I think Wise Mind comes this was in my lectures, which is why I'm like drawing back to it and I recall it. 

I, I think Wise mind is the idea of recalling or using your mind to replay your values and ultimately what you hope to accomplish, what you want to get done, and then finding a way to reframe your emotions with your ultimately wise mind goal.

And I think this is, I want, you could correct me, I'm gonna correct you for taking a Freudian route here. Okay. You're correcting me. 

Margaret: I'm already here. Yeah. What was your Freudian route though? I'm curious. 

Preston: Oh, I guess I was gonna say it's like almost like your super ego. So it's your way to [00:39:00] navigate between your it and your ego.

Margaret: Yeah. So I'm gonna correct you. so Wise mind is like the combination of like rational and emotional mind. So a lot of people will kind of be like. I don't need to think about how I'm feeling. I just have to do this. Like I need to be doing this. It doesn't matter if I'm sad or in grief, like I need to go on my, to continue with the running metaphor.

I need to do my marathon running training. It doesn't matter. Da and emotion Mind, which is like often people then, if you are like doing a DBT group on Wise Mind, people will be like, well, I can't let my like, and, they're in DBT, like, let's say specifically for borderline personality disorder. they'll say, well, I can't let my emotion mind win.

Like my emotions are the ones that got me here. They're the ones that led me to like self-harm and do like, have like suicidal thoughts or like have this relationship go how it did like or spend whatever. and so when you're doing Wise Mind, that'll often be like, I have that sense of almost like a really tight control.

Like I [00:40:00] have to use my rational mind and my emotion mind is bad. And that kind of like rigidity can lead to staying in this like. Back and forth or this kind of like rollercoaster of being hyper in control and then totally like burning out and being out of control. And what we want is to help people figure out how to integrate the emotional self or the feeling self, the not perfectly quote unquote rational self.

And then the like, productive, organized, reasonable self. I'm doing a lot of this because I don't actually think these are separated out in this way, and I would say most db t people either, but, '

Preston: cause those can be productive. But I guess I'm picturing, you know, the two, I guess like the angel edema on your shoulder.

And one is like, like we can only do what is logical. You have to follow this regimen. Like clearly there is no benefit in being emotional, therefore I will not be emotional. ha Yeah. See, and the other side is like only emotion. You're like, okay, one or the other. But [00:41:00] the dialectic is, or the wise mind is your ability to like combine both of them because we are emotional beings.

There's no denying that. And also. When people think about like logically the best thing to do, it's usually driven somewhere at its core by an emotion. 

It's just like trying to be hidden somewhere. So there's no true only pragmatic self. There's no true only emotional self. Okay. 

Margaret: Right. 

Preston: This makes sense.

Margaret: Yeah. So why is mine very important, topic. So those are, that is a very brief overview of the mindfulness foundation pillar of DBT. The next one they go that we go to in the book and often in groups is emotion regulation. which is like everyone, I think a lot of times people hear this and they're like, yeah, I mean I'd love to regulate my emotions.

It's like, 

Preston: that's why I'm here. 

@abbiecantwell: That's why I'm here. Yeah, exactly. 

Margaret: I think one of the best parts of the emotion regulation that I don't hear people always talk about outside of DBT, that I feel like things in [00:42:00] emotion regulation, distress tolerance, like tip skills or other components will get kind of like.

Taken out and put on a worksheet in the hospital outside of the rest of the context. But one of the really, I found important parts of emotion regulation as a pillar in DBT is understanding and then applying why we have emotions and what their like evolutionary theoretically at this point in the science like function is, but also how they're helpful and not the enemy.

And if you think back to us just talking about Wise mind, there's something in that too, that if we let emotions mean something and be helping us in some ways a lot day to day, then they don't become this thing that we get phobic and rigid and controlling around if they are not just like our enemy.

Preston: Mm-hmm. 

Margaret: And so one of the parts of emotion regulation that we won't get into is just like going through and kind of saying like, well, why do we experience sadness? Why, what might be the evolutionary benefit to [00:43:00] a human being that experienced sadness when that doesn't, 

Preston: I would say, It's evolutionarily to help us appreciate movies better.

Margaret: Okay. Now gimme a real answer. 

Preston: You're set. Oh, okay. Okay. Yeah. Anthropologist Press would say that things like sadness, shame, love, these are all like very pro community. Mm-hmm. So, the, ability to mourn someone even like before and like after they have died, those, are, things that bring us together.

They're very strong. 

Margaret: Mm-hmm. 

Preston: like bonding, mediators of bonding and, I guess sadness also exists as the antithesis of happiness in a lot of ways, which is also very like pro community. So, one of the reasons why homosapiens were even able to succeed better than like Neanderthals or other, I guess Homo Subspecies was our ability to have like large [00:44:00] groups that worked together.

Margaret: mm-hmm. 

Preston: Complex organization and I think our emotional systems are one of the ways that we are able to do that. 

Yeah, 

And even things like empathy or like your ability to recognize strong emotions in other people helps you attend to their needs. So not only is sadness a way for you to like mourn someone or be close to someone, it also can be a way for you to signal help to other people.

So if I'm sad and I express that sadness, then my community can function a little bit better because people can come to my aid. That's my thought. 

Margaret: And no, exactly. I have, nothing else to add to that. I think also like I've nothing else to add, but I think helping people like see the use of them.

Just a lot of people, by the time they get to DBT and I, think this is true outside of borderline personality disorder. By the time they see us, period, their emotions have been a problem for them in some way in their life. [00:45:00] Whether they've been too much or too little or you know, whatever. And so I think if we can bring ourselves back to neutral and also find some of the good that exists, even in challenging to experience emotions, there's like, you're not particularly fucked up inness about them then that's not a clinical term.

But there's, you know, there's a sense that like, this is our common humanity, which is less isolating than like, you are a sad person that is just sad and everyone else doesn't experience it like this. And then it helps them, it helps, it can help people relate differently to the emotions so that there's less of the maybe like quote unquote maladaptive or less skillful responses to emotions that are more desperate or feel like I'm just fucked forever.

So like, why would I even try a different pathway? 

Preston: and I think that it also helps from a wise mind because you're teaching someone that your emotions are not just. Pesky things that need to be [00:46:00] suppressed, but important to weave into your identity and concept of self and how you navigate the world.

Margaret: Exactly. some things in that we won't get into in this part that stay on for the Patreon part, and we'll maybe do a couple of, we're gonna practice a couple skills together. and emotion regulation is like kind of the basics. Again, a lot of the DBT skills overlap in the pillars, but things like mindfulness of current emotion probably does sound like mindfulness, which is why it's the foundation.

But opposite action. Love that girl. Love opposite action. We've talked about that, I think mm-hmm. On the episodes with both Dr. Cook, with Dr. Brook and with Amanda. so we won't go into it here, but then like, problem solving, accumulate positive emotions in the short term and long term cope ahead. Plans cope ahead is.

Goes platinum every single quarter in my therapy clinic. I love, a, girls. I love a COPA head plan. and then [00:47:00] please, which is an acronym for some of the emotion regulations skills slash things to reduce vulnerability to emotional highs and lows, like getting enough sleep or exercising or eating enough throughout the day.

things like that. So, lots of skills. We'll get into more of these during our episode with, Dr. Fowling, but we, 

Preston: do you have any thoughts on that? So acknowledge both like the psychological and biological aspects of emotions. Mm-hmm. 

Margaret: So, 

Preston: so this pillar is really, it's normalizing the fact that emotions are there and they're okay.

And then let's look into psychologically how we can control our behavior to handle them, but also set ourselves up for success by, working on our bodies so that our bodies experiencing emotions in a better way. I think, yeah, I can't imagine trying to do all this stuff while also being hangry and sleep deprived.

I think, that would just make it more, 

Margaret: I mean, you're, I'm on call today and you're on call tomorrow, so, we'll, we have, some great time to practice not being [00:48:00] regulated. 

Preston: I'll be getting my please skills tomorrow morning. Let 

Margaret: me working on them. pillar three is distress tolerance, which again, I think we get to this pillar in groups.

People are like, yeah, of course I would love to tolerate distress. And I'm like, girl, I get it. so distress tolerance. If you think of emotion regulation as this pillar, that's like understanding your emotions, how they work, and then also like working to make them more workable through a number of things that you, we just mentioned.

Right? Distress tolerance is like, well, the really intense challenging sensation or emotion is here or situation. Mm-hmm. Now what. And now how do we get through these without blowing up our lives? Like how do we make, continue to build a life worth living even when these really intense emotional sensations are here?

Preston: And so this pillar is more pragmatic. 

Margaret: I would say. This pillar is more like we're in distress versus like emotion regulation is like the whole span of things. And this one's kind of like mm-hmm. This is when a lot of the [00:49:00] behaviors that people end up seeing us for happen is when they're in this like really intense kind of crag of emotion.

And so I think these are the DVT skills that are more of like, how do you get out of this crag without blowing up the mountainside? 

Preston: These, are emergency procedures. 

Margaret: Yeah. 

Preston: Okay. 

Margaret: do you know any, can you guess any that are in distress tolerance? 

Preston: well there's, I guess there's like controlled breathing skills.

So that's one. And then there's, You can actually, like, you can redirect, like sensations. So things like ice, I think other like options. So like, I mean a lot of people already come, like patients already come to this conclusion that like if I, create like a really strong somatic sensation that helps cope me cope with the emotional distress that usually manifests as self-harm.

Mm-hmm. So like a kind of ice is another way to like redirect it with while still being more adaptive. 

Margaret: yeah. So you're mentioning a lot of the tips [00:50:00] skills, which is one subset within tips 

Preston: skills. 

Margaret: This, 

Preston: okay. 

Margaret: Yeah. 

Preston: Yeah. I think that's 

Margaret: other ones 

Preston: about all I have 

Margaret: in here are radical acceptance, which I love.

Everyone hates when you, I also love to use the word willingness, as you guys know. willing hands is like a physical exercise you do that is like, reminds you, like you literally put your hands out when you're in the moment. So these are like in the moment skills that we're using, right? turn the mind.

Distraction with accepts, which is like a bunch of things you can use for distraction, self-soothe, improve the moment, which are like different approaches to make the moment of challenging emotion like better even though you don't get rid of it. and then half smiling, which I just wanna end with because I think that's the one that I've never had success.

Like, have you tried like, hey, have you tried just like smiling a little bit when you wanna 

Preston: wait it, that's a real one half smiling. 

Margaret: Yeah,[00:51:00] 

Preston: that makes me think about, I think it was a study from the nineties where they said, you know, evidence shows that if you smile, you can make yourself feel happy. Is that 

Margaret: mm-hmm. 

Preston: Is that where that comes from or like 

the, 

Preston: inspiration for that? 

Margaret: They're like, yeah, they're basically like softening your expression.

I think they're also, in some ways, one of the things that I think when it does work is like, it is that it's like a conscious, like kind of, Executive function, engagement of some other part of your body rather than just like the rumination or spiral that you're in. So I think though, even though it's like silly, whether it's true of like smiling a little bit, listen, we don't really need to love every DVT skill, but even if it's like smiling a little bit itself doesn't actually really do anything biologically, I do think there's probably something of like, I have something I can do, it's something I need to focus my attention away from my like current thoughts or emotion experience and like focus on trying to smile or open my hands or do whatever and get myself out of the rumination.

but [00:52:00] yeah, it is one of the skills. So tomorrow, if you get too many pages at like midnight, just remember to smile a 

Preston: little bit. Be I'll be half smiling tomorrow. Yeah, don't worry. 

Margaret: I'll be half smiling. I'll be 

Preston: full smiling. that's the high fidelity call model is pressing. Doing his tips please.

and high smiling 

Margaret: smile. Smiling is way through the hospital. our last pillar is interpersonal effectiveness. Do you remember any of the ones for this? 

Preston: I do, actually, I know something about this. Okay, so 

Margaret: interpersonally effective a time or two? 

Preston: Yeah, I've, been interpersonally affected as well. 

Margaret: Oh.

Preston: so if I remember right there, there are like kind of three concepts that you have to hold together. when you're looking at relationships, which are like three values. So you have the value of your own dignity, the value of the relationship that you have with a person, and then the [00:53:00] value of whatever this kind of encounter is contended on.

So, because interpersonal effectiveness ultimately is about navigating conflict with other people, and that conflict comes from competing and sometimes mutually exclusive interests. So the example that comes to mind would be interacting with your landlord. So. You have your own dignity, you have your relationship with your landlord, which you can value however much you want.

And then you have like the cost of rent, which literally has a monetary value. So let's say your landlord is trying to dip you out of your deposit. 

Margaret: Mm-hmm. Like 

Preston: you leave and he's like, oh, I, saw a, there's like a dent in the wall over here, so your 1400 deposit, you don't get it back. How do you navigate that situation?

That would be like something in interpersonal effectiveness. 

Margaret: Mm-hmm. 

Preston: So that's all I know there may be other aspects to it. 

Margaret: Yeah. That one section that I think is like a core component that is reiterated throughout the skills. [00:54:00] there's give skill, fast, dear man. clarifying goals and priorities.

And then I think one, that's one I hadn't heard of until I was reading this book was I hadn't heard it put as a skill, which is determining level of intensity when asking for something or responding to a request. And there's this interesting, so. I have the book right here. So I have Dr. Fell's book here, and then there's like the cards that came with it.

And we were, I was on consults and we had some like complex situations happening in the hospital that we were consulted on. And so I had brought the cards to work and jokingly was like, let's all pick one and we'll practice in the interpersonal effectiveness skills today. And I had gotten this one and it's like the dimes skill.

but it ha it's like this list of 10 questions and it's like everyone that is like a, yes then you like should try to go assert yourself. And if it's like a no, then you like shouldn't. And they were fascinating. So that's the skill I want us to practice in the Patreon part. [00:55:00] but then Dear man and other things, I think they're also like, they, it sounds really clunky.

I think a lot of things at DVT sound like very clunky and like, okay, that's not gonna work for me, but often. There's this assumption that we just know how to emotionally regulate or do interpersonal dealings with one another and like we don't, or we've been taught really ways that get activated that aren't helpful.

And I think one of the big strengths, especially about the interpersonal effectiveness components of DBT, is that it actually gives people like a literal script to start with and is like, how would you even say this? Which I think is part of why people like our podcast is like, we'll do the role playing where it's like, how does this even sound to try to, you know, enact a therapy skill or something, dah.

So I think that is a strength of like the d, this part of DBT as it gives scripts. 

Preston: Yeah. On the intro it sounds vague and iffy, but when you actually do it, it's a concrete roadmap that you can read off. That's exactly, that's like where it makes its money. 

Margaret: That's where big [00:56:00] dbt, that's where Fidelity, dbt, yeah.

Preston: That's where the fidelity comes in, 

Margaret: goes the bank. so those are the four pillars we. We'll have Dr. Felling on to talk about components of this that I think we can give more nuanced clinical situations of like how to apply these. and then if you are on Patreon, you will hear us in a few seconds practicing a couple skills from the book slash just seeing if we can use it for while we're both on call this weekend.

So we will see you in the Patreon section in just a second. You can catch the next part of this on Patreon. 

Preston: It's patreon.com/happy Patient Pod. We're back. We're the main, we're back. We're in the mainland. 

Margaret: You missed so much in the page transaction. 

Preston: Well, thank y'all for coming through this DBT journey with us.

I, this was a good refresher for me and I'm, you know, maybe selfishly I get to use this podcast to, to relearn old topics, but I think is like the point of why we did this in the first place. This is the point we're 

Margaret: like, this 

Preston: is weird. We lit like kind of learn and chitchat and be like, oh yeah, Like [00:57:00] I do have a wise mind somewhere in there.

Theory in theory. At least in theory, it's not just all my emotional mind driving. It's 

Margaret: all 

Preston: practice. If you guys like these shows, like come to the therapy episodes, let us know. I think we've been having a good bounce of them dipping into politics a little bit too. Everything's political.

Therapy is political, so I guess at the end of day we are a politics podcast just despite the categories we put ourselves in. If you want to come chat with us, both Margaret and I monitor the, how do be patient 

Margaret: our monitoring spirits 

Preston: Instagram. Yeah. You can always find me at its pre or Margaret at Batard every day.

Or you can go on the website how to be patient pod.com and leave any messages directly chat out to all the listeners that are saying nice stuff. Somebody sent an email the other day. Oh my God. I wanna, find someone 

Margaret: asked if we could do an episode on feminist therapy. The answer is yes. Yeah, 

I 

Preston: should have had it more ready.

Margaret: And also the Spotify comments, you will find me lurking there. That is for some reason the [00:58:00] place I'm most drawn to, to respond to people. I'll be like, on my way, I'll like be making a playlist for my Pilates class that week, and I'll be like, let me just see what, how to be patient has to say about it. 

Preston: You know, it's a unique spot.

The Spotify comments, because y'all taught me that you could even comment on Spotify in the first place. Yeah. So comment on Spotify. we'll hard it and reply. 

Margaret: We'll be like, Hey. Hey girl. 

Preston: Thanks again for listening. We're your hosts, Preston Ro and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristen Flannery, Aron Korney, Rob Goldman and Shanti Brook.

Our editor and engineer is Jason Portizo. Our music is by Omer Ben-Zvi. To learn more about our program, disclaimer and ethics. Policy submission, verification, licensing terms, and our HIPAA release terms. Go to How to be patient pod.com or reach out to us at how to be patient@humancontent.com with any questions or concerns.

How to be patient is a human content production.[00:59:00] 

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [01:00:00] background.