DBT Case Studies with Expert Dr. Kiki Fehling

Preston: [00:00:00] People in general just struggle thinking about their phone that way. Like, oh, it's the darn phone. It's ruining my life. But also it keeps me connected to all these people. How do I all these do in my hand how to be patient. 

Margaret: Welcome back guys to how to be patient. We are very lucky because we have gotten another really cool person and expert to hang out with us.

We have Dr. Failing with us today, who's gonna talk with us more as our part two of hopefully many going forward. But part two of our DBT series, Dr. Failing, you don't know this maybe, but we have been in between DBT and existential psychotherapy and going back and forth in the last four episodes, and so we have been, if threads of existentialism come into our conversation today, that is why.

But first of all, welcome to the podcast. I don't know if you wanna give our listeners a little bit of your background and introduce yourself. 

Dr. Kiki Fehling: Sure. Yeah. so [00:01:00] I am a licensed psychologist and an, Linehan board certified expert therapist in dialectical behavior therapy or DBTI mostly spend my time now spreading the, gospel of DBT through writing and speaking.

Ah, my book, yes. writing books, writing articles, being on podcasts like this one. and I am not currently practicing, but almost my entire training and therapy giving practice has all been focused on DBT. So it's definitely the love of my clinical life at least. 

Margaret: And we have so many questions for you on how you ended up in this and we'll get to that.

As always, we do an icebreaker, and the icebreaker for today is related to DBT. And it is related to the kind of helping our mental emotional world by taking care of our physical self. And so all three of us work in mental health. Many of our listeners are healthcare workers or in helping [00:02:00] professions where they're very people forward, mental health forward, which takes a lot of regulation day to day.

and so I, our icebreaker today is what each of our favorite either within the classic please, set of things in terms of the, I'm gonna pull it up. You could probably list this off the top of your head, but treating physical illness L is l 

Dr. Kiki Fehling: if that's also physical illness. Oh, it's physical. It's one of the, 

Margaret: this is why I can 

[music]: remember this one 

Dr. Kiki Fehling: understandably.

It's, one of the acronyms that Marsha kind of takes, lives some liberties with, in my opinion, takes 

Margaret: iness, 

Dr. Kiki Fehling: uhhuh, 

Margaret: exercise balanced eating, avoiding mood altering substances. Balance sleep. And then the last one is exercise. So the classic ones or just ones you found? 'cause there's definitely ones that I have outside of that I think are, all of us pick up things along the way that it's like I have to do this or I really do notice my emotion regulation or just baseline is [00:03:00] different.

So that's our icebreaker for today. 

Dr. Kiki Fehling: Yeah, mine is definitely, I mean all of the police skills are useful obviously. But the biggest one for my mood I would say is exercise. I love CrossFit. I love running. I'm a really athletic type of person, so exercise for sure. I do wanna put a plug. There are some folks in the DBT field who are trying to make DBT more neuro affirmative for neuro diversion folks.

And so they've included an S at the end, so please is, and they've made it, talked about sensory health. Oh, and that's one that I've really started to deeply appreciate kind of paying attention to sensory under and overstimulation and being more aware of that during my day. 

Margaret: I love that. I feel like that's such a good ad and also gets a lot of the things I'm thinking about in my head that like, help me end or open days working in the hospital.

Preston, do you have, yours? 

Preston: I'm actually practicing mine right now. It's eating, I think it [00:04:00] exercise is helpful to me, but honestly if I'm hangry, I think that's like the greatest detriment to be being able to use like effective coping skills. So I do this, like I finish clinic and then I often have 15 minutes to get to this podcast.

And like my number one priority is like I need to eat so that I can be like present and interest. Otherwise, like it's just not gonna work. So I'm, I have some cheese right now. It's like goda that I got at Whole Foods and then some crackers and I'm trying not to chew into the microphone, but when we have breaks this, is my Please skill that will be working actively.

Margaret: See, I like love asking people this kind of question, who I work with. 'cause I didn't know that. I didn't know that, like, I mean we all have to eat, but that's your one. Which ironically mine is sleep and I'm in Boston and so we always film at this time just because of like working with our producers, working with our weird schedules.

and so we always end up filming until like 8 30, 9 depend, depends [00:05:00] how things go. But I definitely start to fade outside of when we're filming the podcast around like seven 30. 'cause I work out in the morning and so sleep for me is definitely one. And I feel like nothing made me realize that as much as, and sleeping at night specifically as like being on nights or doing 24 hour shifts.

Even when I got to sleep in the hospital, it was like I felt so out of my body and like, sounds were so much worse for some reason, or just like, you just feel nauseous after working at 24. And so I think for me, obviously no one's feeling great after 24, but sleep is such a big one. 

Preston: It's like some people just don't respond negatively to not sleeping.

Like I, I think what's profound to me about the police skills is seeing when some people aren't affected by them. 

Margaret: Yeah. 

Preston: Like some people are like, yeah, just like, I don't know. I just forget to eat happens to me. And that that could never be me. Or I had friends in med school, they just didn't need sleep that much, or they advertised it that way, led me to believe they didn't need sleep, because [00:06:00] who knows, you know, you're not actually Superman.

Dr. Kiki Fehling: Yeah. I've experienced that with clients too, kind of sleep being on the back burner, but then when you finally focus on it, it's like the thing that changes everything if we can get them to go to bed at a regular time. So yeah, I think they're all important. 

Margaret: Yeah. It's interesting to think even, 'cause I feel like Preston, I tend to lean more that way of the, like I can be someone that eating is like not obvious to me.

Not in a, like I'm avoiding it way, but it's kind of like it'll just simmer and I'll feel like fine. But I feel like last year I started. Wanting to like actually hit my like five a day of like produce and like eating more regularly. And I was like, oh, it's actually kind of nice, like not waiting to eat until one 30.

Yeah. Which I was not doing on purpose. It was just like what would happen? I was like, wow, I actually don't feel tired in the morning. Now 

Dr. Kiki Fehling: imagine that. 

Margaret: Imagine that. Yeah. Yeah. So I think one of the things that really has drawn me to DBT [00:07:00] has been some of the concrete things that it offers I the love of my clinical life.

I don't know if we were talking about this on here, love of my clinical life is act, but DBT comes in a close second. and mostly because I think it does offer all these different handholds on for people to be able to really concretely take from the abstract sky that can be psychotherapy sometimes and apply it to their life.

and so before I ask you how you ended up being an expert DBT and being, you know, one of the actually Linehan certified, true DBT. Disciples and teachers out here, I do have to say a correction to our last episode, which is, which in which I erroneously said that Marsha Lenahan had died. She has not, I need our producer to not put these sound effects in there.

she's alive and well. I don't know why I thought that so confidently. That is my bad. 

Preston: I 

agreed confidently too. 

Margaret: You did. I apologize to Marshall Lenihan. If you ever hear this podcast and are like they're spreading lies about you. I am so [00:08:00] sorry. Thank you. To our listeners who commented, we can't get it right a hundred percent of the time.

and that was a big incorrect one. So my bad. Formally 

Preston: Marshall Lehan, you were very much alive. 

Dr. Kiki Fehling: Yeah. And like you said, it's an easy mistake to make. I think when you think about like the legend that she is, it almost feels like she should be historical. 

Margaret: Yeah. For some reason when I, read, because I read her memoir and I feel like for some reason I thought her memoir came out after she had passed away.

So I was just wrong in multiple, ways, but, Stepping around and moving away from my air. I would love to ask like how did DBT become, as you said, the love of your clinical life? 

Dr. Kiki Fehling: Yeah, so I knew that when I was applying to grad schools, I wanted to research and work towards reducing suffering specifically in the area of suicide and self-harm.

And, I was working at mass gen at the time when I was applying to grad schools and I had my first taste of DBT there 'cause there were some amazing DBT clinicians, at [00:09:00] the hospital. They were doing a DBT trial for, treatment resistant depression, and I got to attend the skills groups and it was really cool.

And then I was very lucky to get into Rutgers University in New Jersey and where there happens to be one of Marsha Lenihan's students, Dr. Sherine Vy working there, I was in her research mentee. But, I worked with another person there in suicide, but then was able to train with her clinically. And it was very obvious, just like right away, taking her class.

Everything about DBT just clicked for me. I'm sure we'll talk more about it, but even the concrete skills, the radical genuineness of the therapist, and the therapy relationship and dialectics in general and even like the ability for DBT to zoom in and zoom out, kind of hold both acute moments and like bigger life worth living, cultural, frameworks, like all sorts of big and small things in the therapy space [00:10:00] that.

It just fit for me. And so I was lucky enough to get training in DVT throughout my entire graduate training and then to get more on internship and yeah, I've been DVT the whole time kind of unexpectedly, even if I didn't go to grad school for that. 

Margaret: I'm just thinking about being in like med school, grad school and actually like one, the like academic joy of finding something that you philosophically are like, oh, this is what I've been looking for.

But then also concretely being in grad school and being like DBT skills probably would be good or are life skills as they say. and probably I'm just imagining like if I had DBT skills in med school, how would life have been different? 

Dr. Kiki Fehling: Absolutely. It was life changing for me personally in a number of ways.

As someone who was always emotionally sensitive and you know, I studied suicide and self-harm 'cause I had experienced some of that myself and had friends who, I had a friend who died of suicide and so it was very personal. And then learning these skills and really personally experience how [00:11:00] transformative they are through my own life.

But then also through the lives of my clients. it's really, it's hard not to fall in love, I think when you do comprehensive DVT. 

Margaret: Yeah. Yeah. No, I feel like, one of the reasons I feel so connected to ACT is because I was diagnosed with OCD and like Scrupulosity as a kid. And so I don't know that my therapist, who I eventually went to in med school would've called what he was doing act.

We've talked about this in hindsight. He is very act informed. And so it's definitely like a different thing when you're like, I have taken the medicine or I have done the therapy or the skills and applied it to my life and. Not that it's the right fit for everyone, but like I know that this can be so life changing.

And I think that felt experience within the, treatment is usually pretty helpful to patients if we can like, offer it even like, not in a direct way, but in a felt sense with them. 

Dr. Kiki Fehling: Mm-hmm. 

Margaret: And sounds like DP T Yeah. Made a lot of sense to you. 

Dr. Kiki Fehling: Yeah. When I'm, orienting a new client to the therapy, it was [00:12:00] very easy to convince them that this therapy would help them not only 'cause of the research base when it's someone with BPD or severe suicidality, being like one of the few therapies that can help in that way.

But then on a personal level, for anyone coming in with high emotions, it was. So wonderfully useful for the therapeutic alliance for me to be able to say like, actually, I totally get it. And this thing helped me and it's gonna help you too. Like, I swear, and you know, it doesn't always work out the way you want it to, but there's always something in DBT skills that can help people.

And that's, another reason why I really like it. 

Margaret: I think one thing I wanna ask, I guess, is how you transitioned from the clinical side to working more, like, the way I found you and started following you is through your videos on TikTok, which as a chief teaching last year, I like showed to people as part of like my like little resident lecture and I've shared, I think in other ways, but I've found them so helpful.

I know they're like actually on one of the like, right, like primary DBT [00:13:00] websites too. So clearly you have a gift for teaching, you have a gift for this work. How did you end up being in this more public facing space for DBT? 

Dr. Kiki Fehling: It's definitely not something I ever. Imagined for myself in grad school on, that's for sure.

On me. Yeah. I mean, I feel like I wasn't even a social media girly, like in my personal life, so it felt like came outta left field. yeah, I, was even late to the game in terms of TikTok. Like I didn't join in 2020 when there was this surge in COVID, but I think it was in late 2021, I read an article that blew my mind, and I think more people know this now, but, and I can't remember the exact data, but the article was talking about how some huge percentage of Gen Z people like using TikTok as Google, particularly for health information.

And I, was like, what? Like, I can't imagine doing that. 

Preston: Oh yeah. I was, I think it's about 60%. [00:14:00] when I was, when we were at the A PA, I think we went to like a conference that was discussing it, or like one of the sessions, I'm not sure how the population has changed, but that was actually one of their like rallies was.

You know, your patients are getting, whether you like it or not, are getting their information at this source and you need to meet them where they're at. 

Margaret: It's the water they're kind of drinking primarily from. 

Preston: Mm-hmm. 

Dr. Kiki Fehling: Yeah, exactly. And so I downloaded the TikTok app, like I actually had avoided it and typed in DBT and BPD and PTSD and I didn't love what I saw, so I was like, okay, I guess if I can even just make basic psychoeducational information about this, I don't know how it'll go, but I can do it.

And then one of my first videos, I, still can't believe it. I came onto TikTok right around when the Korney kid meme was taking off for the tiktoks out there, and I made a video about the DVT skills I heard in the Korney Kids song, and it did really well. And then I just had more [00:15:00] fun from there.

And, I'm just, I'm really glad I did it because it led to a lot of different opportunities and meeting people and yeah, it's pretty cool. 

Margaret: Yeah. So it was kind of born of a place of like. People are getting information here. I'm not seeing the information that I know from my, like clinical and research work works, and like, if not me, you know, who's gonna put this information out there?

Like who's, and I wonder for you if there was any, like, I don't know, maybe I hate the term imposter syndrome for a number of reasons, but we won't get into, but like, what was it like to, like, did you talk to anyone that you were gonna make a video? Was it like, when you first posted, you were just like, no one's gonna see this, so whatever.

Like, what was your mental going into even just making something and posting it? 

Dr. Kiki Fehling: I, had a lot of shame and social anxiety even thinking about going on. So no, I didn't talk to any of my colleagues because I wasn't sure what they would think about it. And so I'm like on the app kind of sitting and watching for.

[00:16:00] I don't know if it was weeks or months, but it was a while before I made content myself. And then I'm like at the gym one day thinking about it and I'm like, you know what? I am like not walking the walk of a DBT therapist. And my very first video was about using opposite action to social anxiety and shame and making a first video.

So I, for folks who don't know, opposite action is a skill from DBT that's all about reducing emotions that we don't want to be feeling. 'cause they're not helpful for us in that moment. And so I made a video about, right now I am practicing opposite action to anxiety and not planning and thinking and I'm not gonna edit this video and I'm just gonna post it and see how it goes.

And even that video, like none of the catastrophes happened, so it, yeah, it was useful for reducing that anxiety and then it got easier from there. But imposter syndrome is real for sure. 

Margaret: it is. I think the beef I have with imposter syndrome sometimes is that I think it's often like thrown on like very quickly to women of like do imposter syndrome and then.

Also, it's sometimes inappropriately thrown to people like [00:17:00] of color or other people who are like very clearly qualified and then asked it. And the second thing is there's, there is one load-bearing tweet for me that it's like, it's not imposter syndrome if you're just like not qualified. And so that's the other side of the coin that's like, do you have imposter syndrome?

Or like, I think of like myself as like a med student. It's like, girl, you just like, that wasn't, you just didn't know. You weren't like, I wasn't beating myself up. It was just like, it's not imposter syndrome if you don't know sweetie. So that's my like one-sided beef with that term. Preston, you look like you're thinking hard on something.

Preston: Yeah. Yeah. I have a one-sided beef with it too. Maybe. I think when people use it, it's a way to almost like humble signal. 

Like. Like, I know you feel like you deserve to be in this room, but be like, ah, just the imposter syndrome's getting to me guys. You know, like, I'm clearly, like, you guys think so highly of me.

I guess high, you think higher of me than I think of myself. I think is almost like a way to come across humble. Mm-hmm. Underhandedly. [00:18:00] so I think maybe I like brush up against that, but that might just be me, like peacocking with other white males or like whatever we do when we get in a room, we kinda like circle each other, you know?

And we're like, oh, you know, 

Margaret: like, 

Preston: I know you, you're not an imposter. I'm not an imposter either. Just lean into it bro. 

Margaret: Like who's the lead? Whatever. yeah. So then the videos did well, the first few videos did well. How were, had you already been in the like, experience that you were like working on this book?

Which I highly recommend and also was just like. I don't say this about every book we have, but it's just like, it's a nice paper. Like, it's like thick in the right way that it's like holding and like, I just like really like the design. Like, I don't know. I think it's yes, regulating from a sensory perspective as well.

Smells 

Preston: good too. 

Margaret: I mean, the, it doesn't have my favorite thing from regular books, like from like literature where it's like the edges of the paper are like not the same. But I don't think any book has that. I think you'd have to be like Viktor [00:19:00] Frankl for the book to be that. But, it's just, it's a beautiful book.

I just wanted to say that, but how, was this already part of your career direction or has this been part of the social media stuff as well? Same question for the cards, which I also really like. 

Dr. Kiki Fehling: Yeah. So I had, I'm trying to remember the timeline. I am pretty sure I had started writing the book by the time I'd gotten on to TikTok.

But they were unrelated. the book came a part. I was invited to write the book and I'm so grateful for that. 'cause I'd always wanted to write a book and now like I'm writing more, which is wonderful. and then the TikTok just came out, like it wasn't a requirement of marketing or something like that.

I know some folks talk about that. it was really, as I said, just that psycho ed. And then, and then I liked it and then did help, kind of get the news out about my book. So, and also thank you. I'm very proud of that with my co-author and I wish I could say we like did the graphic design, but we did not.

So thank you to my publisher for [00:20:00] that. 

Margaret: Yeah, I mean, I think it's like, I feel like there's, this is sort of true in like academic, like healthcare or psych, like psychology, mental health stuff where it can be like, there's great information, but then the packaging doesn't do the information justice. And I think that's like a conversation that.

When we were at APA or that we think about the podcast, we all three of us think about with social media and then even with this book, that it's like, does someone want to have this on their shelf and therefore make it more likely that they'll pick it up and use it does, you know, how does it feel in their hands?

And they pull it off the shelf at their local bookstore and does that feeling, invite them to have more curiosity. So kudos to you guys as publisher, because I don't know that always happens in these kind of books. 

Dr. Kiki Fehling: I agree. And especially the cards, like the pastel Rainbow. Like, I remember when my friend got the deck, they were like, it's like the, apple of mental health cards.

It's just beautiful packaging. Yeah. Which 

Margaret: like, I, brought these into clinic the other day and I was sitting with a [00:21:00] couple of my co-fellows and a couple attendings, and one of them, a couple of them both took pictures of them, were like, I need to get these. so they saw them and they were like, again, they like liked the design.

Were like, those would be helpful. One question I have for you that Preston and I talked about with the cards, so I think the book, the how do you imagine people using the cards. Not like the tarot thing I posted, although I still think that's a fun way to use it. You can like, what do I practice today?

Dr. Kiki Fehling: Yeah. Yes. So the cards are probably gonna depend on what the person's, how their use is gonna depend on how the person has, what their preexisting knowledge of DBT is. There's pros and cons to this, but I did try to write them to be potentially helpful for both people with minimal knowledge and folks who'd been through a full round of skills, for example.

So the way that I imagine the cards being most useful is for, I mean, there's so many acronyms. So even just studying and like memorizing things for folks who want help doing that. But then as kind of just prompts, like the thing that I [00:22:00] really imagined was someone in DBT or self-studying DBT skills, picking a card each day by ran at random and then like reminding themselves what that skill is and then trying to practice that skill during that day or something like that.

The other really hands-on thing that I have also personally found the cards useful for is creating coping plans. 

Margaret: Mm-hmm. 

Dr. Kiki Fehling: Yeah. So I have some clients who are super visual and it's helpful to be able to say, okay, for this cope ahead that I'm trying to plan for this upcoming stressor. what is what's on that plan?

And having the cards like out in front of you and being able to move them around or take a photo of the, cards in the line of what you intend to do. Like, that's some other ways you can play around with it. 

Margaret: No, I think that's, there's like a lot of ways I can imagine using them and I think similarly, like I'm in child fellowship now, so I work with teenagers a lot in therapy and I think one of the things I'm always thinking about for earlier teenagers, but also older teenagers, and maybe we should [00:23:00] think more about for adults is the sensory kind of aspect of learning or the just other ways of approaching to actually make these things sort of grab-able in the moments of distress when they need them.

And if we only give them this like. I told it to you one time in a lecture, can you remember it on the most stressful emotional test of your week? Probably not. Like that's not, you know, we know that from other ways of learning and so I think that's helpful. I also just always like giving people something like this may be the psychodynamic part of me, but I like, like for there to be things that they can physically take or just are more like even don't, if they can't physically take them, are kind of sticky to take out of sessions that we can keep referring back to, to build upon instead of it kind of feeling like it goes to the ether after a session each time.

And I think that these cards could be really helpful for that too. 

Dr. Kiki Fehling: 100%. If you are willing to par with a card as a therapist giving a card to a client each week to take with them as homework basically. 

Preston: Mm-hmm. I think [00:24:00] gamifying anything, especially in our generation, helps make it stick. You ever see those videos where it's like information about how, I don't know a sawmill works, but they sing it in a song.

Yeah. And I'm like, dang, I locked in that whole time. So it makes me think of these games where, you know, you play like Texas, hold them, but reverse and you like hold the cards on your forehead. 

Margaret: Oh yeah. Oh yeah. Which, what is it? It's like, oh, you would use this when, 

Preston: yeah. So like 

Margaret: day you didn 

Preston: sleep there, you describe this skill and I have to guess what it is.

Margaret: You didn't eat that before the podcast. You should have practiced your X skill, like, 

Preston: oh my please. Skill. Yeah, exactly. But I, think even that like, it allows you to interact with the information in different way because unlike other therapies, I feel like DBT has a lot of information you have to consume and it's also a kind of a language that you have to learn, so mm-hmm.

You're, both part therapy group and part classroom, I would say. And this, I think these cards really help with the classroom portion of it. 

[music]: Mm-hmm. 

Dr. Kiki Fehling: Mm-hmm. [00:25:00] I do. It's not mine, but I mentioned my mentor earlier, Dr. Sheen Rizvi. She and one of my colleagues, Jesse Finkelstein, recently released a book too called Real Skills For Real Life.

It's fabulous book. 

Margaret: Yeah. 

Dr. Kiki Fehling: Yeah. I maybe even on my TikTok, because I'm obsessed with it. It's, I it's really lovely. trying to find a good page. They have made pictures of all the DBT skills, like, and they've created videos on YouTube. Jesse actually created a card game about DBT skills. I think it's called The Game of Real Life.

So there are other folks approaching it the way that I'm trying to, that you all are describing of like, how can we actually make these skills accessible to people where they're at? and traditional therapy, let alone traditional books and all of the things don't always work for everyone. 

Margaret: I think one of the reasons that, one of the things we try to do with our podcast, and I think one of the reason that people like it is not just because like we're making jokes or trying to make jokes and being entertaining, but because it's like.

We are taking [00:26:00] these, we're taking these concepts and we're playing them out. Right? Or we're asking kind of weird questions about it that make it so that there's a slightly different thing for them to hold onto. Whereas I think both for the people who listen to our podcast to learn or are people listening to learn it just for themselves, it can be hard to keep all of this information in.

And I think we know that also as like med students doing things like Sketchy micro, which is like little cartoons that they were like, and then you remember this is in the picture because this antibiotic has this side effect, whatever. and so, yeah, I think the, like part of this mission of like getting DBT out to the public is asking why it's so slippery for people.

And the first thing is just like knowing DBT exists one. but I do think there's been more public coverage on that in recent years with like some celebrities and influencers have talked about it. Getting the therapy. I don't know if you have any like, thoughts on that or experience of like, do you think the [00:27:00] public knows about DBT more or do you think it's still not very well known?

Dr. Kiki Fehling: Both. Mm-hmm. Not to be a DBT therapist, 

Margaret: but dial about 

Dr. Kiki Fehling: it. 

Margaret: I 

Dr. Kiki Fehling: do. Yeah. I do think that more people know about it. Like you said, people mentioning it, like DBT skills or DDBT concepts or DBT specifically. oh my gosh, what's the Marvel character? Who's Green 

Margaret: Hulk? 

Dr. Kiki Fehling: Hulk, like it was on the Hulk. Yeah.

I'm like, sorry. and like, celebrity Selena Gomez talking and I think Demi Lovato talking about DBT stuff. So I think more people know about it and there's still a lack of knowledge of, especially as you said, high fidelity, DBT or comprehensive DBT. Being so useful as a treatment for BPD specifically is still super unknown, I think.

and so that's where maybe we have to try to keep getting the, news out there. 

Margaret: Yeah. Yeah. [00:28:00] We have more to talk about. We'll be right back after we take a quick break.

We know that a lot of people who listen to our podcast are also therapists and maybe running their own practices. And as someone who is brand new to the game of opening my own private practice, simple Practice has been a really, important tool for me. 

Preston: Simple Practice is an all-in-one EHR that is HIPAA compliant, high trusts certified and built specifically for therapists.

It brings scheduling, billing, insurance, and client communications into one place so you're not juggling multiple systems to run your practice. 

Margaret: One of the features that I'm really excited for that can help with the business side of things is automated reminders for your patients to help reduce no-shows as well as other components of billing and insurance to make the business side a little bit less of a heavy lift.

Preston: And if you're just starting out or growing your practice, there's also credentialing service that can take the headache out of insurance enrollment, which can honestly be a huge lift. [00:29:00] So if you're ready to simplify the business side of your practice, now's the perfect time to try Simple practice. 

Margaret: Do it with us.

Preston: Start with a seven day free trial, then get 50% off your first three months. Just go to simple practice.com to claim the offer. Again, that's simple. practice.com

Margaret: Before we get into a couple situ situations is maybe the wrong term, but a couple situ. No. Okay. We're gonna do our usual thing where we act out some of this to make this a, these concepts a little bit more as we're talking about concrete and memorable. Before we do that, I think one question I just selfishly wanna ask you is, and this is, you can defer this question if you want to, but selfishly, I kind of wanna ask you as a DBT therapist, what do you think DBT has to offer the problem of like teens, young adults and adults with overusing screen time?

Dr. Kiki Fehling: Oh, [00:30:00] 

Margaret: uhhuh. Which I ask this because I like thinking about this in the ACT perspective. And so any self, selfishly, again, anytime I get a chance, I'm like, okay, I need an art therapist on. And I was like, tell me your thoughts. So same question for you with DBT, someone's struggling with like, I'm on my phone for way too many hours, but I feel like I get stuck and I can't get off.

Dr. Kiki Fehling: Oh my gosh. I think that there ha, it has, a lot of potential benefit actually, to my knowledge. I don't know if anyone is looking at this, but I, just imagine it would be a really good fit. The same things that make. DBT and DBT skills useful for substance use disorders mm-hmm. I think would be relevant here in terms of that addictive quality.

And so mindfulness, like the ability even to just be aware of one's behavior on a cell phone, which is inherently so difficult would be useful. DBT, there's so many techniques and skills that are designed to help a person change behaviors, whether do more things [00:31:00] of that they wanna be doing or do less of what they don't wanna be doing.

And that is all across the gamut of mindfulness, emotion regulation, but also behavior change skills. setting up the environment, like changing your phone, changing the habit of how you use your phone, being willing to delete the apps, which is really hard to do, et cetera. But then grounded in, I imagine this would be relevant for act too, like really tapping into the why of doing that really hard thing because there's, because it is addictive and everyone is doing it and it's really easy to do.

So tapping into the values and the goals for like, okay, why do I wanna spend less time on my phone? Right? To make it easier to sustain that behavior change, which is gonna be so hard 

Preston: and the dialectic that my phone is not just evil and there to suck my time away. And it's also a tool that I can use, but it hurts me in these ways.

I think that's, people in general just struggle thinking about their phone that way. Like, [00:32:00] oh, it's the darn phone. It's ruining my life, but also keeps me connected. All these people. How do I hold these two in my head? 

Dr. Kiki Fehling: Yeah, I think that's a great point because I mean, and that is when you get split into those two sides, right?

That's what makes the behavior change more difficult too, because you're either like, oh, my phone's a fucking worst and I can't do anything. Sorry, can I swear 

Margaret: here? Yeah. Every 

Dr. Kiki Fehling: episode 

Margaret: is rated E on our podcast, 

Preston: rated E for everyone's gonna say fuck.

Dr. Kiki Fehling: Exactly. Or like, I don't know. I have to be online because it's good for networking or good for my social life, or whatever, and those things might be true. So just being able to figure out, okay, in this world where my phone sucks and it's great, what can I do? 

Margaret: yeah. Okay. Are we ready for what makes a lot of our guests nervous, but is just live action, role playing?

So I have scenario one. We love to do it. We [00:33:00] love to do it. I'm not gonna be making, I'm not gonna be an like an outlandish, fictional character. I'm gonna just be a conglomeration of things. I'm actually not a fictional character at all. I'm not a real person either. But before, like often when we do this, like I've been eo, I've been singer Jessica Parker.

It's 

Preston: just talking, learning about sex in the city, honestly. 'cause I don't watch the show, but it's just been through these role plays with Margaret. 

Margaret: Yes, we've been to Simpsons and Couples therapy. 

Dr. Kiki Fehling: The voice was really good. 

Preston: Oh, thank you. 

Margaret: Okay, so for this first one, I may throw Preston into the second one, but the first one I'm gonna give you guys a scenario.

So Preston is going to be your first year, second year psychiatry resident, or third year who's rotating with you in a DBT clinic that you don't have anymore. But he's rotating with you in a high Fidelity DBT clinic. So there is groups, you are having the team meetings, there's other people supporting me as a patient.

But you are my, let's say, primary person I'm meeting for the first time after this referral from my very [00:34:00] well meeting psychiatrist. I, my clinical vignette is I am a 19-year-old college student with a history of, binging and purging at one point met bulimia criteria. and then there's been question of if BPD is there, but main thing that they're worried about and wanting me to get help with is that I do struggle as well with self-harm in addition to purging, I self-harm via cutting.

There's not, there's passive kind of chronic si, but there's never, been like an attempt or planning. And then I really struggle interpersonally with like emotion formation, attachment and regulation. And one of the big things that's been hard for me lately is my college boyfriend broke up with me right before finals and then I failed a few exams and I was self-harming really bad.

That got me upgraded level of care. So it is now a new semester. I'm coming in, it's February, and I'm coming into your [00:35:00] clinic. I'm meeting you, and I am a 19-year-old coming in to start doing DBT therapy one-on-one with you, and then also do groups eventually. that's our situation. And so I'm gonna be that person and we're gonna do it for five minutes.

And so you can say, you can decide with Preston as your faithful and, eager, psychiatry resident if you want him to start with me and you'll be there. Or if you wanna start and how you guys wanna do it. So I'll let you two. pick that. 

Preston: Well, well, we can talk outside the room. Yes. So Margaret's, in the room right now.

I'm in the 

Margaret: room 

Preston: and she's been roomed. Okay. Hey, or what's that other, podcast. Knock, knock. Hi, I'm the new med student, our new psychiatrist resident working with you today. 

Dr. Kiki Fehling: Hi, nice to meet you. Or 

Preston: oh, hey. Hey, doctor. Dr. Fan. I've heard a lot about DBT, so. I don't know how to do this, but however you wanna do it, let's, let's go forward.

Dr. Kiki Fehling: Mm-hmm. So are you saying you don't know too much about DVT yet? [00:36:00] 

Preston: Well, I mean, I know there's like those four pillars, the emotion regulation, interpersonal effectiveness, distress tolerance, and mindfulness. So, and I have done some mindfulness courses in the past before, and I, if I do say so myself, I think I'm interpersonally quite effective.

Though I don't know much about how to teach someone else about it, it's just kind of, you know, I'm born with it. 

Dr. Kiki Fehling: Wonderful. I think. Yeah. Yeah. Okay. So if, since we're gonna meet this person for the first time when we start DVT, one of the first things you need to do is, like commit, get commitment to therapy.

We call it pre-treatment. Oh. In the first four sessions. So in this therapy, what we're trying to do in that pre-treatment is get the person to understand what DVT is and how it might be able to help them specifically. And so I am leaning towards taking charge of this visit myself if you're not sure what DVT is.

Preston: Yeah, I think that sounds good. 

Dr. Kiki Fehling: Okay. so what we'll wanna do, just so you know, where, my head is at when we go in to [00:37:00] see the, patient is I wanna get some basic information from her about what's going on and what she knows about DBT, and then probably introduce her to the biosocial theory of DBT, which is kind of the main underlying theory and model of emotion dysregulation in the therapy.

Preston: Okay. So we're gonna teach her about what DBT is, and really this is about getting buy-in from the beginning. So that Right, she's invested in her own care, like we can't be making this decision for her. She has to make the decision 

Dr. Kiki Fehling: 100% in DBT. That's actually super important. We get really explicit commitment in a way that you don't necessarily get as explicitly in some other therapies because it's a lot of time and a lot of effort to do DBT.

So we wanna make sure that she's in it because it's gonna get tough. 

Preston: Gotcha. Should be dialectic behavior, commitment therapy. Really. I think 

Dr. Kiki Fehling: sometimes it feels like that. 

Preston: Anyways. Okay. I'll, go in right after you. I'll be like a fly on the wall except for when I talk. [00:38:00] 

Dr. Kiki Fehling: yes. Yeah. Feel free to jump in and ask questions or validate if you want to.

Mm-hmm. 

Preston: Okay. We're walking down the hall and Hey, nice to meet you. 

Dr. Kiki Fehling: Hi. 

Margaret: Hi, I'm Helga. 

Dr. Kiki Fehling: Hi, Helga. I am. I'm Kiki. And this is, 

Preston: oh, I'm Preston. Hey, nice to meet you. I'm a psych resident. 

Margaret: Okay, cool. 

Dr. Kiki Fehling: I'm a psychologist in the DBT practice and I was told to come meet you 'cause it sounds like I might be your individual DBT therapist if you decide to join the program.

Margaret: Yeah. I thought I already was joining the program. 

Dr. Kiki Fehling: Oh, great. Well, so if you are. Fully bought in. I'm glad to hear that. and in the first few sessions together, I do wanna get more information about you and tell you a little bit more about DBT to make sure you think it's a good fit, because I know oftentimes people get referred and aren't too sure about it.

Does that sound okay? 

Margaret: Yeah. Yeah. My psychiatrist, Dr. Duncan, just sent me here. So like, I'm kind of a little bit [00:39:00] like, I definitely want, from what she described, I wanna do this, but she's also just hurried sometimes and just refers me to things. So I'd love to hear more, I guess about it.

I know I meet with you and then I do like groups, and that there's like emotion regulation, but that's I looked on TikTok a little bit, but that's kind of all I really know about it. So I'm, really open to it and like things have been really hard and she said it could help. 

Dr. Kiki Fehling: Okay. Can you tell me a little bit about what she told you about it that makes you already think that it would be helpful?

Margaret: So, I don't know how much you guys know, but like I, I like had a really bad, like first semester of my freshman year at college here. And I like, I feel like I've struggled with like anxiety and like depression and stuff for longer, but like, I don't know, I felt like I was able to kind of hide it more, just deal [00:40:00] with it.

But then I, my boyfriend from home and I, like, he broke up with me like right before finals in December, Arnold. And he, like, I'd like, we'd been dating since high school. I like liked him. we'd been friends since we were kids and then it was just like, he was the only person who could ever like, take care of me and like make me feel better.

And, it was just like, I felt like the bottom dropped out from under my feet and I like was self-harming. And anyway, I, she was saying that like some of those feelings I was feeling. Like the self-harm and some other stuff maybe like is part of how I respond to my emotions and like they just feel so big and she said this could maybe help them like, I don't know, feel less big or like, not like I'm afraid, like right now I feel fine, but it just feels like that like ship starts sinking randomly if like one thing goes wrong for me sometimes.

Dr. Kiki Fehling: Mm-hmm. Mm-hmm. Well, I'm really [00:41:00] glad that Dr. Duncan referred you because what you just described is exactly what DBT was designed to help with. So it was designed to help people who feel really big emotions, like you said, or kind of feel like overwhelmed by anxiety and depression and the things that life throws at them.

And then they don't know how to cope with the things that life throws at them. And so then they do the best they can by self-harming or engaging in other impulsive behaviors like drinking or binging or purging and other types of coping strategies like that, and can feel kind of lost and overwhelmed and not know how to do anything but those kind of self-harming behaviors.

So it sounds like that resonates with you. 

Margaret: Yeah. Yeah. Multiple of those. 

Preston: You're doing the best you can and you're hoping to do better. 

Margaret: Yeah, I guess I, I mean, I guess like I feel like it's hard 'cause like my mom would always be like. Want me to like, I felt like she didn't understand. And so it, it feels like I'm, like, [00:42:00] would try to cope and it would be things that I like then felt worse about with how I coped.

Like even this, like that I failed a bunch of my tests and like relapsed and self-harming, 

Dr. Kiki Fehling: but then like 

Margaret: growing up there wasn't, like neither of my parents knew how to like help me. They'd kind of just be like, do better. So I don't, know. I think it makes me like a little scared to hear, like, I guess I'm hoping this isn't just gonna be like a push through it.

And that's kind of what's made therapy like not helpful for me before was like, I felt like the therapists were just like, just get over it, like my parents. 

Dr. Kiki Fehling: And if you could, you'd be doing that though, right? Like that's not helpful. 

yeah, So no, you're in the right place then. So what I can tell you about DBT is not only was it designed to help people who feel emotions really intensely, but one of the ways it helps.

Helps those people is to teach them really concrete coping skills to help in these moments. How can I better understand how I'm feeling? [00:43:00] How can I feel things and go through stressful like breakups and exams and all of the terrible, stressful things of life without feeling overwhelmed by it? And then how can I also like get more that I want from life?

How can I get more happiness and connection and joy and fun? so the way that we do that is by, as I said, teaching those concrete skills and then helping you get to know yourself better and learn how to not only support yourself but communicate with other people in your life so that they better support you.

'cause it kind of sounds like maybe you haven't had the support that you've wanted from your parents and others, some other folks besides Arnold. 

Margaret: Yeah, I feel like I always am trying to like be thoughtful and really aware of everyone, but it feels like that's not. It feels like my parents couldn't do it.

And even with like my friends, especially like being new at school and like not knowing people that it just, I don't know, it feels [00:44:00] sometimes like I'm like the only one who like cares and I like know that's not true, but yeah. But I also know like what I'm doing is not helping me either. And it's like cutting myself isn't, it makes me kind of feel calmer, but like, it doesn't, I don't wanna be doing that.

Like I'm, I wanted to go to college and be like, you know, we were gonna, like, I was gonna visit with Arnold and I was gonna like major, like pick my major and like build this life that's different than how high school was. And now it just feels like everything is fucked. 

Dr. Kiki Fehling: Mm-hmm. Yeah. 

Margaret: Yeah. I guess that's like, honestly how I've been feeling lately is like I can do day to day, but it just feels like I've always felt like this.

And I'm like, on one hand I'm like excited for this therapy, but I'm also No one's been able to help me the last like five years and, 

Dr. Kiki Fehling: mm-hmm. 

Margaret: Yeah. 

Dr. Kiki Fehling: Yeah. So first of all, I'm not sure why you apologize when you said that life feels fucked. Like you're allowed to swear in here. You're allowed to [00:45:00] express anything you feel like One of the things that I'll tell you more about is it's gonna be super important that you are honest with me and that you tell me when I do things that annoy you when I do things that let you down, that when the therapy feels like it isn't working, it's, there are these things called therapy interfering behaviors, which is just anything that you or I do that might get in the way of DBT working for you.

So I want you to tell me when those things are happening for you so that I can change or I can help us figure out together how we can change it to make it work for you and be a team so that you get what you want out of this. So like your anxiety about this therapy makes perfect sense and I want you to know.

That, that's gonna be something that I'm gonna be checking in about a lot 

Margaret: and time. Great job. Great job in our clinic. Sorry, Preston. I didn't have much role for you as the med student. 

Preston: I mean, I'm, I think it played it effectively. 

Margaret: You were, it was [00:46:00] subtle, yet great support. 

Preston: Mm-hmm. 

Margaret: Just the, nod and wave boys.

yeah. We are gonna take a one more quick break and then we'll be right back and we'll talk about how this went. And also some sense of like myself as being a patient, your sense as a clinician and kind of what's common or not, and these mm-hmm. Sort of intakes, so we will be right back.

Okay. So one of the parts that we always do whenever we do one of these role plays is before I ask anything or press and ask anything, is we just say, as you know, how did that feel? and so I, my question is, Preston, for you is like the kind of person sort of in the dynamic, but mostly observing it is like, what did that, did anything about that surprise you, intrigue you, make you confused?

What did you think of that dynamic? 

Preston: I think I was pretty sold on DBT. I mean, I guess I wasn't the primary customer in the room, but like the way Dr. Pha [00:47:00] was describing it made me wanna try it out myself. I think, you do, Dr. Failing, you do a great job of describing all of the problems that someone might have, and then how DBT specifically addresses those problems.

I think sometimes we go about it backwards where we're saying, here's all these things about the therapy and why it's so great, and also you have these problems, so this therapy should be helpful for you. And so it's almost backwards that we'll present them. 

[music]: Mm-hmm. 

Preston: Whereas, you know, you start out with that reflection, normalization, it sounds like.

Having trouble managing these big emotions and have I got news for you? I've got a tool that was designed primo to handle big emotions. You know, I was like, I need some of that, right? I'm like Carl on the table. You know what I mean? So even just as a, I was like, yeah, I'm buying this. 

Margaret: Yeah. I really liked how [00:48:00] I mean I think obviously the anytime starting new therapy, like wanting your therapist to, as the patient be like open and warm, but then also like clearly able to guide the ship.

I think sometimes there be times where it's like you leave the therapy even as like a patient, but like you leave the therapy and you're okay, even if I don't feel confident about what we're doing, if the therapist was like. Open to my feedback. Right? Like, and I really like that you said therapy interfering behaviors is something either of us could do that would get in the way of us connecting, which I think is a rare but important humility to carry into any therapy.

but also that it was like, you know what you're talking about and you can respond to my concerns. And I think until there's more rapport built that like ability to trust that this person knows how to drive is like an underrated part of rapport, in therapy. So I really liked that as like the patient.

Dr. Kiki Fehling: Yeah, you, I mean, from [00:49:00] my perspective as a clinician, really what I'm trying to do is, what you both said, like kind of almost like a motivational interviewing, session really to see like, what do you know about this? And then fill in the gaps if they're not there. But allow the person to already start convincing me that this is what they need.

And like I know what DBT is, but they know who they are. And this is something I will say explicit to me, explicitly to my clients before we commit of like, I am the expert in DBT, but you are the expert in you. And the entire therapy is going to be geared towards your life worth living goals, what is most important to you, what you want out of life.

And everything is geared towards that. And we're gonna be working really specifically and acutely. Repeatedly on the same behavioral goals of like things you wanna do more of and things you wanna do less of that you will help define with me. Like I'm not figuring that by myself. DBT is gonna make someone stop [00:50:00] self-harming.

That's basically the only black and white, thing we require of our clients, but everything else is like up in the air. So it's really about giving the, client, and I hope Helga felt this of like 

Margaret: Helga from Hey Arnold. By the way, for listeners listening, 

Dr. Kiki Fehling: I figured, 

Preston: oh 

Dr. Kiki Fehling: yeah, I figured 

Margaret: say football head.

Dr. Kiki Fehling: I love that. Yeah. And starting to, in the back of my mind, I'm starting to see the things where. I get to be able to jump on the Biosocial model to teach Haga about like the ways that strong emotions show up for her and why that might be. And then the ways that it sounds like her parents and some people at school, I think, like invalidated her, and contributed to those emotional difficulties and say like, that's where we're gonna try to change that pattern.

Margaret: Yeah. Yeah. I, have a couple questions. One of the questions is, do you consider yourself, like, what is the difference between like DBT [00:51:00] and radically open DBT? 

Dr. Kiki Fehling: Ooh. So I don't have training in R-O-D-B-T, but, the main, like theoretical and practical differences from my understanding is R-O-D-V-T is more about helping folks who have emotion dysregulation that looks like over control.

So anorexia, difficulties related to being autistic, like OCD, OCPD, that kind of thing while DVT, Normal close traditional DBT? Yes. Closed db t 

Margaret: normally 

Dr. Kiki Fehling: closed 

Margaret: db t This is exactly open, 

Dr. Kiki Fehling: yeah. Is more about emotion dysregulation that looks like under control, quote unquote. So impulsive behaviors or difficulties with sense of self, like lack of and self insight and knowledge or rules and values.

It's really not that clean and simple. I've helped plenty people in with closed DVT with nor with regular DVT [00:52:00] with those disorders. Mm-hmm. and with issues of over control and like perfectionism and things like that. But that is, that's kind of the broad difference between the therapies. Although R-O-D-B-T includes a lot more skills and things that aren't in traditional DBT from my understanding.

Margaret: And is there a difference in like the orientation or the stance, like of the therapist in R-O-D-B-T? Like in terms of outside of like skills, like, I'm just thinking of like. How do you, what is the feeling of like an analyst sitting in the room with you versus the DBT versus CBT versus act, whatever? Like, is there a difference in terms of the like humor and kind of equality in the room that you think about with classic DBT?

Dr. Kiki Fehling: Yeah, so DBT is a really, flexible therapy where DBT therapists show up differently according to like their own personalities. And the thing that I have heard is, you just nailed it, of like R-O-D-B-T therapists are much more likely to include humor 

Margaret: and 

Dr. Kiki Fehling: your reference really actively. And like Almo I've heard, I only know one person who practices it and [00:53:00] the way he's described it, it's like being goofy on purpose.

Mm-hmm. It's like trying to break social rules or social expectations almost as a way to create looseness and like fight the rigidity that can show up. 

Margaret: Yeah. Interesting. 

Preston: I mm-hmm. I actually had some interaction with this. I had an attending who like. I don't know if he was practicing radically open DBT or if he would describe it this way, but 

Margaret: just off the rails.

Preston: Yeah. He's just, a guy discovering it. You cowboy DT you know how, like, how it's like the bow was invented both in Asia and South America mm-hmm. That had different names for it. Yeah, that was him with radically open DBT. but he, had therapy with a lot of OCD patients, highly restricted patients.

And I remember one day we're walking and he goes, you know, the thing about OCD patients is you gotta introduce a little chaos because that's what's, that's what's gonna get him to open up and start talking to you what actually matters. And he tells me the story about how he's like, he'll be sitting behind the desk and like [00:54:00] asking, you know, the patient like, Hey, you've been taking your meds.

They're like, yeah, I've been taking my meds. And he is like, really? And then he just like throws a card, like throws a sticky note to the edge of the table and the patient's like staring at it, like, why'd you do that? And then he just throws. All of the Post-It, post-it notes up in the air and they're like littering down around them.

The patient's like freaking out and they're like, no, I've been taking my meds. Like, why would you do that? And he's like, why would I do that? And then like, then all of a sudden they're actually having like an engaged conversation. So I'm not sure if this guy's just absolutely cavalier or just going off the rails, but when you're describing kind of the intentional humor, breaking down social norms, it just made me think about attending, throwing his business cards or sticky notes in the air and watching them rain down around this patient with OCD and destroying their sense of control.

Margaret: You know, the movie, everything Everywhere, all at once, where it's like, 

Preston: mm-hmm. 

Margaret: You have to like, like, it's like something surprising has to happen to break the cycle and go into the next form or whatever, where it's like, what is that? Like? Never let them know your next move. It's like, [00:55:00] well, whatcha gonna do now?

There's no clear social rule. Uncertainty is here and like. I just broke all your scripts. That's interesting. Mm-hmm. I will say I feel like an act sometimes, like when you see the videos of like Steven Hayes, it's like, I don't know that's how I practice act. And act is similar where there's like a lot of flexibility in how you show up, but there's also like levity and humor and you know, taking a step back, whatever.

but some of the videos of him, like doing these like practice things with patients where like he just will choose like a really weird metaphor and it's like so throws them off that they're like, they are kind of like thrown onto another track and interacting in a way that is different than the way they're used to or predicted they would.

So, and we should all start throwing cards 

Preston: or Fritz Pearls with his like, gestalt therapy. We watched a video of that last time. 

Margaret: Oh yeah. 

Preston: that was like kind of a way to break the ice and like precipitate affect, like we were talking about affect blocking, and our existential psychotherapy podcast.

And one way to get around [00:56:00] affect blocking is to focus on every person's. Immediate reaction, even if it would be, gosh, in a normal social context with the caveat that you avoid just intentionally rage baiting the patient. Just, but anyways, yeah, so Fritz Pearls would do that, I think, well in gestalt therapy, and he is dead actually.

So, March 19th, 1970, Pritz Pearls passed away. So just throwing that out there. Okay. 

Dr. Kiki Fehling: I think you nailed it for like the conceptual station in DBT would be the same, basically like trying to support exposure and emotional experience. 

Margaret: Mm-hmm. You know, I don't agree with CBT people that much, probably more than is actually necessary, but I will agree with them that at the end of the day, end exposure is often king.

We just all, we put different words around it. You can catch the next part of this on Patreon. 

Preston: It's patreon.com/happy patient pod. 

Margaret: Dr. Ing, where can people find you on the [00:57:00] internet? Where's the way they can keep learning more from you outside of this episode? Because there is so much more we could talk, there's, you know, 120 or whatever cards more we could talk about.

So where else can they learn from you? 

Dr. Kiki Fehling: Yeah, so you can go to my website, which is my name, kiki failing.com, but you can also find me on most social media, at the handle at dbt Kiki, which is definitely a love, as I said. but I've also recently started writing on substack, specifically focusing on L-G-B-T-Q mental health.

So you can find me there under the Substack How to Queer Joy, 

Margaret: which I believe is what you're working on for your next book, 

Dr. Kiki Fehling: correct? That's right. Mm-hmm. 

Margaret: When and what is the expected timeline for your next book to come out for our very engaged listeners? 

Dr. Kiki Fehling: Yeah. So the LGBTQ plus mental health workbook will be coming out in June of this year, 2026.

Cool. 

Margaret: Amazing. 

Preston: Wow. 

Margaret: Well, maybe we'll have you back on and we can talk more in depth about that new book, which I'm sure there's, I mean, there's [00:58:00] still so many things we can talk about DBT alone, let alone more like different approaches for LGBTQ plus clients that a lot of therapies and the history of therapy has not addressed well, which we talk about 100%.

Yeah. Okay, great. Yeah. Well, thank you so much for coming on. Preston, do you wanna take us out? 

Preston: Thank you for listening, for being here, letting us join you on your walks and your runs or your drives. Special shout out to wandering, On YouTube, they wrote, this is the only thing I look forward to on Monday.

And, that's been weighing on me not in a good way, like it, you've been, with me even on Tuesday, Wednesday or Thursday. And right under that, Layton Olson said, complete freedom is an impossible delusion. We are all in varying degrees of bondage. And that is just, I think, the perfect supplement to that.

So. Thanks again for commenting. Hack yourself. 

Margaret: I'm waiting. 

Preston: You read your Spotify comments and your YouTube comments and [00:59:00] they really do make our days. 

Margaret: We do be in those Spotify and YouTube comments. 

Preston: You can always leave a comment there or you can just send us a voice note on our website. We'll look through those as well.

We are meant to do an episode. Reading off some voice notes might be coming soon too, but we do have them in the archive. You can find us on Instagram and TikTok at Human Content Pods or contact the team directly ahead of you. Patient pod.com 

Margaret: or our Instagram, how to be patient. Pot. 

Preston: Yeah. It's, like, our mini Neo pet between me and Margaret.

It's, we are closing. 

Margaret: You don't know who's 

Preston: Plus. Yeah. It's one of us and we won't tell you who, if the poor 

Margaret: diva has said it all, it's me, as you guys know. 

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

Our editor and engineer is Jason Portizo. Shout out Jason for all the music and sound effects you give us and cutting and uncut 

Margaret: and fixing my 

Preston: life. our music is Bio [01:00:00] Marvin's v. 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.

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 [01:01:00] background.