219 ‒ Dialectical behavior therapy (DBT): skills for overcoming depression & emotional dysregulation

1. 0:00 – 0:08

   Intro

   1. PAPeter Attia0:00

      [upbeat music] Hey, everyone. Welcome to "The Drive" podcast. I'm your host, Peter Attia.

2. 0:08 – 6:15

   The basics of dialectical behavior therapy (DBT) & how it differs from cognitive behavioral therapy (CBT)

   1. PAPeter Attia0:08

      Hey, Shireen. It's great to finally meet you, uh, not in person, but, uh, better than being on the phone, I guess.

   2. SRShireen Rizvi0:14

      Yes, same here.

   3. PAPeter Attia0:16

      So, um, you know, people on this podcast have probably heard me in a couple of episodes reference this thing called DBT. Uh, I've never really gone into much detail about it, but it's something I've wanted to obviously have a dedicated podcast around and, and now we're finally gonna get to do that. So, I mean, I guess maybe we can just start by kind of defining what it is a little bit before we get into its history, uh, its founder, your, your involvement and things like that. So i- if you were at a party and somebody said, "Shireen, I, I, I heard that, you know, you're a DBT therapist, uh, and a practitioner. Uh, can you tell me what that is?" What would you say?

   4. SRShireen Rizvi0:57

      Sure. So DBT stands for dialectical behavior therapy, um, abbreviated DBT, and it's a form of therapy or a form of talk therapy that is largely inspired by cognitive behavioral therapy, also abbreviated [chuckles] as, uh, CBT. So we often say that DBT is a form of cognitive behavioral therapy that was designed for individuals that have complex mental health problems, and originally designed for individuals that are, um, suicidal or self-harming, um, and who may meet criteria for a disorder called borderline personality disorder. So, uh, so at its simplest, I would say it's a form of cognitive behavioral therapy that was designed for more complex people or presentations. But then, of course, there's a lot more nuance, uh, beyond that.

   5. PAPeter Attia1:58

      Yeah, which we'll, we'll certainly get into. Um, maybe give people a bit of background on what cognitive behavioral therapy is. I mean, that term I've heard a lot, but truthfully, I don't know much about CBT outside of CBTI, which is-

   6. SRShireen Rizvi2:13

      Mm-hmm

   7. PAPeter Attia2:13

      ... cognitive behavioral therapy for insomnia-

   8. SRShireen Rizvi2:16

      Mm-hmm

   9. PAPeter Attia2:16

      ... which we have referred, I would say, over the past five or six years, probably a dozen of our patients to CBTI practitioners. Um, and I, I think I can say without exception, it has always proved to be incredibly valuable. Not just incrementally valuable, but incredibly valuable. But that's, that's the very limited experience that I have with, with CBT is through that, that one narrow lens. Is there something more broadly we can say about CBT that then allows us to contrast it with DBT?

   10. SRShireen Rizvi2:48

       Yeah. So CBT, it refers to maybe a class of, uh, talk therapy and could often be used to contrast, uh, with other kinds of talk therapy. But some of the distinguishing features of cognitive behavioral therapy is that it's present focused, so focused on what's happening for people right now in terms of the problems they're experiencing, and less focused on one's history, um, one's childhood, uh, less focused on the sorts of things that have led to the person experiencing the problems that they're experiencing. So it's present focused and it's... as the name implied, it's focused on, um, working with thoughts and behaviors that go along with the problems that people experience. So in CBTI, for example, it would be, you know, what are the thoughts that are contributing to your insomnia, uh, and how do we work on modifying or changing those thoughts that you're having in order to increase the likelihood that you fall asleep, let's, or stay asleep? What are the behaviors that you do that promote sleep? What are the behaviors that you do that get in the way of sleep, and how do we modify that? So at its most concrete level, it really is working with thoughts and behaviors that, uh, in the present that are contributing to your problems right now. So it's very much an active problem-solving approach. And I think what is, um, with people who don't have a lot of experience with therapy, uh, or, um, receiving mental health treatment, they might have an idea based on the media or TV or movies that the best therapy is one where you just go in and talk about whatever's on your mind. Uh, and CBT and similarly DBT is much more structured and, and guided, um, than that. And the other, the other distinguishing feature I will say about CBT and DBT is that, um, it's evidence-based, meaning that we, um, construct treatments, uh, in a way that we could measure its effectiveness. And if we find that something is not effective for people, then it's not likely to stay in the therapy. That's, that's our goal anyway, is to be as empirical in our, and scientific in our approach as possible.

   11. PAPeter Attia5:21

       So how long has CBT been around as a discipline?

   12. SRShireen Rizvi5:26

       I would say it emerged, uh, you know, probably the figure that is associated with the beginning of CBT is a man named Aaron Beck, uh, who, um, died last year, I believe, at the age of 100. Uh, and so he, or something, uh, like that number, um, I would say it was probably the '60s in which he first started developing his form of cognitive therapy. He was trained as a psychoanalyst, uh, and was seeing that it wasn't all that useful for a lot of the patients that he was treating in psychiatry, and so he started developing an approach that was much more about changing the way people thought, um, about themselves and others

   13. PAPeter Attia6:14

       So

3. 6:15 – 15:22

   Treating depression with CBT: history, effectiveness, & how it laid the groundwork for DBT

   1. PAPeter Attia6:15

      let's talk about Marsha, uh, who is obviously a ve- Marsha Linehan, who's, who's a, you know, uh, I, I, I think it's safe to say really the, the creator and founder of DBT. Is that a fair statement?

   2. SRShireen Rizvi6:27

      Yes, for sure.

   3. PAPeter Attia6:28

      Um, so tell me about her journey. Presumably she had tried CBT both as a patient and maybe even as a therapist before realizing that there was a way that it could be improved upon for at least a subset of patients and/or a subset of problems. Would that be kind of a fair statement?

   4. SRShireen Rizvi6:48

      Yeah. So the origin story of, of DBT was that originally Marsha set out to apply what might be standard, considered standard CBT to folks who were chronically suicidal. And, um, this was, you know, perhaps beginning in the '70s. Uh, she was, um, receiving advanced training at Stony Brook in, um, New York. At that time, Stony Brook was considered one of the premier places to learn and apply behavior therapy. And back in the days of the '70s, uh, '80s, there-- It was really the heyday of, of behaviorism, and the idea was, um, in some way, in many ways oversimplified, but the idea was that we could treat any mental health problem with behavior therapy in very few sessions, um, just by applying these, you know, standard principles of what we know about behavior change.

   5. PAPeter Attia7:49

      Can you... By the way, can you give me an example of what that would be? So does that mean that if, [clears throat] if a person was clinically depressed and came in and they were suicidal, what would the CBT approach have been in the '70s or '80s to a-address that concern?

   6. SRShireen Rizvi8:08

      Well, I might if-- I'll, I can come back to depression and suicide in a minute, but I might start with anxiety disorders-

   7. PAPeter Attia8:13

      Okay, perfect. Sure, yeah

   8. SRShireen Rizvi8:13

      ... because this is actually, uh, what, um, behavior therapy and CBT was probably most, uh, prolific-

   9. PAPeter Attia8:21

      Okay

   10. SRShireen Rizvi8:21

       ... about in those days. And the idea was that you could have somebody who came into treatment with a fear of something, a phobia. It could be something like a fear of heights or a fear of spiders, or it could be a fear of social situations, social anxiety. And the behavior therapy approach to this, or the cognitive behavioral therapy approach to this would be to teach people competing thoughts. So rather than thinking, "This thing will kill me," um, I can learn to have thoughts like, um, "I can tolerate this." Uh, "This might be difficult, but I can, I can handle it." Um, or even have thoughts like, "This is not going to kill me." Um, but those thoughts were only one part of it. The other piece of it was the more behavioral piece, which is, uh, exposure. Basically saying that how you're going to get over your fear of spiders is not to talk about it every week for an hour with somebody, but is actually going to be coming into contact with spiders repeatedly over and over again so that you learn that, uh, you can handle it. Uh, but you also learn that the feared outcome is not going to occur. So, so that was, uh, you know, some of the-

   11. PAPeter Attia9:47

       So change, change your thoughts and get exposure. Change your thoughts, get exposure.

   12. SRShireen Rizvi9:52

       Exactly. And the getting exposure is changing your behavior-

   13. PAPeter Attia9:54

       Mm-hmm

   14. SRShireen Rizvi9:54

       ... because you wanna run away or avoid, and instead it's saying come into contact with, approach something that you want to avoid. [lips smack] And so what they were finding in these, you know, early days of applying CBT is saying, uh, you know, people may have gone to psychoanalys- uh, psychoanalysis, which was the dominant paradigm of therapy in those days. And, and by the way, this is almost exclusively a rich white person issue. When I'm talking about, you know, who was receiving treatment for mental health problems, uh, that's what I'm talking about back in those days, um, largely. And so, uh, people could go to a psychoanalysis, uh, psychoanalyst and talk about their fears for months and years and not necessarily, uh, do better with them. And so CBT comes along and says, "Actually, we could do this sometimes, depending on what the fear is, in one session." There were people who would do like a three-hour session to, you know, quote-unquote, cure somebody of a phobia. And, and they were finding that it, that it worked. And so then you say, "Okay, how do we take those principles to something like depression?" Uh, and this is what Aaron Beck started to do with cognitive therapy more, was noticing that people who have depression tend to think in very particular ways. Um, they have, uh, negative, um, interpretations of almost everything, right? And also about themselves, about their future, about others. And so a cognitive behavioral approach to depression would be about working on changing those thoughts to be more balanced and evidence-based. And then also the behavior change that goes along with depression is usually about getting active. Uh, so when somebody is depressed, the, the tendency is to retreat, shut down, um, avoid. And the behavioral treatments for depression would be to get people activated, uh, and to solve the problems that are causing the depression, whether it's unhappiness with a job, uh, unhappiness with a relationship, and, and work on targeting the problems that are causing depression in a systematic way.

   15. PAPeter Attia12:30

       How successful was it? You mentioned earlier that evidence is a very important part of this. Um, how were they able to tally the results and determine if their intervention was in fact better than the standard of care at the time?

   16. SRShireen Rizvi12:48

       Right. So, uh, the history of psychotherapy trials is largely based on a paradigm known as randomized clinical trials where you would recruit individuals who meet, uh, certain inclusion criteria, say somebody meets the diagnosis for depression, and then you would randomize them to either, say, receive, you know, twelve weeks of cognitive behavioral therapy or receive nothing, um, or receive, uh, treatment as usual or standard of care, and then evaluate outcomes over time. And with things like, uh, depression and anxiety disorders, there are these standard measures that are, you know, popular within our field where we have developed benchmarks for what, uh, we're trying to get to, you know, what might be considered a success. And I would say that in general, the, the trials for CBT for things like depression and anxiety are, are overwhelmingly positive, uh, meaning that most of the trials, uh, especially in the early days when you were comparing CBT to nothing or, you know, treatment as usual, found very large effects, uh, for CBT, um, in those settings. Now, I think, uh, where we see or where we'll come back to Marsha emerging is recognizing that of course, uh, none of these treatments were one hundred percent successful, um, for everybody. And more than that is that when you look at these studies and you see who were these studies done with, the inclusion criteria, meaning the, what allowed somebody to be in the study, were often quite narrow. For example, with a depression study, the person might have to meet the criteria for a diagnosis of depression, but not have suicidal behavior. So people with suicidal behavior may be excluded from a lot of those studies, which, uh, makes sense from a research point of view in some contexts, but in other contexts doesn't make sense because of course, we know that a lot of people who experience depression, um, are also suicidal. So if you're removing suicidal people or not allowing suicidal people to be part of this research, then we don't know ultimately if the treatments work for those populations.

4. 15:22 – 20:10

   Marsha Linehan’s inspiration for developing DBT

   1. PAPeter Attia15:22

      So when did... I mean, Marsha as a young girl, I think, was diagnosed with schizophrenia, is that correct? And was treated with electroconvulsive therapy and all sorts of things that are still used today, but probably not as frequently and probably with a bit more, uh, particular attention to the, the use case. Uh, it was probably used more liberally then, I'm guessing.

   2. SRShireen Rizvi15:43

      Uh, so Marsha was a teenager, I believe, at the time that she was receiving a lot of treatment, and this was in the late '60s if I'm-- no, wait, if I'm remembering correctly, what, uh, when she was born now that I'm thinking about it. But, uh, it was before CBT was really in the picture and she was, um, sent away, uh, hospitalized for, um, being suicidal and chronically self-injuring, doing a number of things to cause physical harm to herself as a way of, uh, relieving emotional intensity and overwhelming emotions. And so at the time, there was not a lot of treatment options that were available, and the medical model was to treat with really strong meds, uh, you know, antipsychotic meds at the time, um, or to use something like electroconvulsive therapy. Uh, and so those were the treatments that she was exposed to from a very young age in addition to therapy, but the types of therapy that she was receiving at that time, uh, were unlikely to be, um, you know, anything like cogn- the cognitive behavioral treatment we know today.

   3. PAPeter Attia17:09

      So how did she find her way from being almost institutionalized to eventually, you know, getting an education and, and herself becoming a therapist? What was that journey that went from that teenage girl to kind of the, the person who created DBT?

   4. SRShireen Rizvi17:28

      Yeah. So she has, uh, written about this in a memoir as well as, uh, described it in a piece in which she, uh, in The New York Times, which was a piece where she kind of came out to the world as having been someone who experienced her own struggles, uh, significant struggles with mental health. And I say that as a preface because, uh, for that article in The New York Times came out, I believe, in two thousand and ten, two thousand and eleven. So for most of her career, she was not forthcoming about this, uh, her own personal struggles. She would tell people that were close to her knew, uh, her students, I was one of them, knew about this experience, but she wasn't public about it. And, um, she would long say that the reason for that is because she wanted DBT to be judged on its merit, um, empirically. She did not want, um, uh, DBT to be judged on her personal story alone. She, she wanted this to be a scientific treatment that, that lives and dies by its outcome, she would say. So, so, um, so when she would talk about how DBT developed, um, to the public is she would talk about it in, um, leaving out this earlier part [laughs] uh, of her own history. So the earlier part of her own history that she describes is that she, she had a spiritual moment, um, when she was in, uh, one of these institutions. Um, and the spiritual moment was that she describes, um, experiencing God in a very dark moment of her own life. And in that moment, she realized that she could... She felt the love of God and felt that she could serve this purpose in life, which is to get out of hell, her own experience, and then to work, uh, her entire life to get other people out of hell. And that was how she took this spiritual experience and developed her life's work based on that. Now, another reason why she didn't-

   5. PAPeter Attia19:59

      How, how old was she, Shireen, at that time?

   6. SRShireen Rizvi20:01

      I would say, um, as best I remember, in her early, late teens or early twenties.

5. 20:10 – 38:15

   Explaining borderline personality disorder (and associated conditions) through the lens of DBT

   1. PAPeter Attia20:10

      Kind of profound to be, to, to follow through on something that, you know, you could argue, well, God, you were still so young when that was happening. And, a- a- and was she at some point here diagnosed as having a borderline personality disorder as well? Or is that something that is more retrospective, where it's sort of like looking back, she was probably misdiagnosed as having schizophrenia? I mean, what, what was the state of understanding of her, her actual condition?

   2. SRShireen Rizvi20:40

      Uh, so I believe that she was probably... You still see this today, but when people are unclear about how to explain someone's problems, they get given almost every diagnosis in the book. And now this would have been before the criteria that we now know as borderline personality disorder being defined. And the way it, uh, is most well known, um, would have started in the third edition of the DSM, which, uh, came out in about 1980. So the criteria that we have now to define borderline personality disorder was not the same as when she was receiving treatment. So I believe that she had a number of diagnoses attributed to her. Um, it's, uh, I can't remember. It's quite possible that borderline personality disorder was one of them. Um, because of course, that's also the diagnosis that they give people when they don't know how to treat them. Uh, and so it wouldn't surprise me.

   3. PAPeter Attia21:39

      And, and what, what are the criteria? Tell, tell, tell folks what borderline personality disorder is today. What do we, what do we know today?

   4. SRShireen Rizvi21:47

      Yeah. So borderline personality disorder is considered a, a complex mental health disorder that, uh, is defined as meeting... There are nine criteria of borderline personality disorder as defined by the DSM. And in order to meet criteria or to have the condition, you have to endorse five of the nine. Um, which actually means that ultimately it's a really heterogeneous disorder because there's all these different combinations and different ways in which one can meet criteria. Uh, what-- One of the things that Marsha did, um, was to, um, restructure the different criteria of borderline personality disorder in a way that, that perhaps is more understandable and also makes more cohesive sense, and to say that it's a disorder of dysregulation across a number of different domains. So the core domain of dysregulation that we see in borderline personality disorder is what we refer to as emotion dysregulation. Um, and this is largely defined by people's experience of emotions as feeling like, um, they have very intense emotions. They don't feel like they can control their emotions very well. Their emotions change very rapidly. So that's referred to as affective lability, that the emotions will go from sa- intense sadness to intense shame, to fear, to joy, you know, very quickly and seemingly without a lot of, uh, reason. So emotion dysregulation is part, uh, and considered core to the disorder of borderline personality disorder. And then these other domains of dysregulation stem from, uh, emotion dysregulation and include behavior dysregulation, so not having control over or feeling like you don't have control over your behaviors. This is associated with a lot of impulsivity and behaviors that go along with impulsivity, so substance use, reckless spending, impulsive sexual behavior, uh, impulsive driving. You know, behaviors that are experienced as impulsive and potentially could cause problems for the person. Impulsive eating, uh, is another domain.

   5. PAPeter Attia24:19

      I mean, it sounds like there's quite an overlap, at least in some of those, with bipolar disorder, right? Bipolar I, where you could sort of see... I don't know about the a-affective lability, but, uh, certainly the, the mania side of it sounds like it might be consistent with some of that dysregulation. I'm, I'm guessing that's what makes psychiatry so difficult, is you don't have biomarkers. You don't have imaging scans that give you diagnoses, right?

   6. SRShireen Rizvi24:45

      Right. Uh, it, we don't. And so there is, you're right, a lot of overlap, and actually probably the ones, the overlap that is more consistent or difficult to discriminate is bipolar II, 'cause bipolar I is associated with-

   7. PAPeter Attia25:02

      The depression

   8. SRShireen Rizvi25:02

      ... longer-

   9. PAPeter Attia25:03

      Yeah

   10. SRShireen Rizvi25:03

       ... uh, longer lengths of either a pure manic state or a pure depressed state. Bipolar II, um, might have manic states, but it is shorter in duration or might not be, you know-

   11. PAPeter Attia25:18

       As high

   12. SRShireen Rizvi25:18

       ... super manic.

   13. PAPeter Attia25:19

       Yeah.

   14. SRShireen Rizvi25:19

       Right, as high. And so that's, that's often really hard to discriminate from, um, somebody, uh, who has borderline personality disorder. And generally what we're talking about with, with BPD as opposed to bipolar is that we actually see the mood changes happening more frequently, uh, within BPD than with, um, bipolar II, but I, I'm probably oversimplifying. But that's what I would be looking for if I was trying to assess the difference between the two.

   15. PAPeter Attia25:53

       A, a person with, uh, BPD, um, what are, what are the challenges that they face in the, in the world, right? If this is a... Let's just assume this is a person of totally normal intelligence and other... All, all physical capabilities are fine, and this is sort of the one issue, this one psychological issue. How does it manifest itself for that person when they're in school, when they're in college, if they get married, if they have kids? Like, he- help, help us understand how this condition makes life more difficult for the individual and, and those around them.

   16. SRShireen Rizvi26:29

       Yes. So one thing I'll say is that you rarely will see this condition in isolation of anything else. And again, this speaks to one of the complexities-

   17. PAPeter Attia26:40

       Hm

   18. SRShireen Rizvi26:40

       ... of trying to study psychiatry, that I think on average people who, who meet criteria for BPD have three to four other mental health problems at the same time. So they'll also meet criteria for depression or an anxiety disorder or a substance use disorder or an eating disorder.

   19. PAPeter Attia26:59

       A- a- and those things aren't stemming from the BPD. These things are, we believe, independently there as well?

   20. SRShireen Rizvi27:08

       Well, I think it depends on who you ask, because I would say as somebody who is trained mostly behaviorally, I would say the diagnosis matters less than how we conceptualize these problems. And to that point, I would agree with you. We could say emotion dysregulation is, is central to all of those things, but the diagnostic system as we currently have it does not allow for that. So they would say, you know, if somebody meets criteria for these other disorders, they also have these other disorders, right? So how somebody with borderline personality disorder, you know, lives their lives, I would say, um, it's complicated because on the one, on, uh... And it ranges. On one end of the continuum, you know, we see people who have, uh, severe problems associated with BPD such that they, they struggle to hold onto a job. Um, so they don't work, and they're on disability or receiving Social Security. They, um, they can't maintain relationships, so they're, they're very isolated.

   21. PAPeter Attia28:18

       And, and why is that? Why are, why are relationships blowing up, and why are they not able to hold down a job? What's the fundamental issue or fundamental issues that are impairing them?

   22. SRShireen Rizvi28:29

       From a DBT perspective, we would say that it all s- um, comes back to difficulty regulating emotions. Uh, so that if I experience intense emotions that I, um, feel like I can't control, when I get angry, I lash out. Uh, when I get scared, I, um, run away or avoid. Um, or I have, uh, emotion dis- One of the criteria that goes along with BPD that you could see as tied with emotion dysregulation problems is what's referred to as fears of abandonment. So a person with BPD often will have a lot of fear that a cl- a person that they love or are close to will leave them. And if I am in a relationship where I am afraid that the other person is going to leave me all the time, that may cause me to behave in ways that are frantic, chaotic, and actually, um, paradoxically have the effect of causing the other person to be more likely to leave, right? Texting the person, calling the person relentlessly. Um, if, if a person doesn't come home or call at the time that they say they will, um, you know, having the experience of feeling like I'm losing it because I don't know where that person is, or perhaps they've, they've left me. As a result, if I have BPD, I experience intense fear, intense shame, intense sadness, and now I don't know what to do with this intense behavior, and I may self-injure as a way of relieving, um, that emotional intensity. Or I may threaten suicide as a way of getting the person to come back to me, and maybe I'm doing this without even having awareness that that's the effect of my behavior. I just know that in this moment I don't know what to do. I feel entirely out of control, and I need to do something to, to fix it in this moment.

   23. PAPeter Attia30:48

       What is the, um, mortality of BPD? I, I, I was very surprised to learn recently that, um, anorexia nervosa has probably the highest mortality of any psychiatric condition. I would have guessed depression presumably. Um, but where does, where does BPD stand in terms of mortality e-either through self-harm and neglect potentially or, or obviously suicide?

   24. SRShireen Rizvi31:14

       I sometimes get into the weeds a little bit about this, and when, as a, as an academic and psychologist, what I find, and someone who studies suicide, I review a lot of manuscripts and, and grant proposals, and I am always, um, uh, saddened and amused, uh, when I see people, you know, write about a disorder and say, "This disorder has one of the highest rates of, of suicide." Because if you look at it, it seems like every disorder has one of the highest rates of suicide. And I think it's because we don't know how to study this very well, honestly. We, we don't know how to, um, how to determine of the people who die by suicide, what are the mental health conditions that they had, and what is the relative risk according to these different disorders.

   25. PAPeter Attia32:09

       Yeah. Well, especially when you overlap, because as you said earlier, if a person with BPD also suffers significant depression, if they commit suicide, are we attributing that to depression or to... Yeah. So, so, no, I think my question more broadly is knowing that one could never tease that out, how risky is it for an individual understanding all of the comorbidities that, that tend to cluster with it?

   26. SRShireen Rizvi32:35

       I will say it's very high, and one way in which I can answer this is that one-- another criteria for, for BPD is, uh, repeated or chronic self-injury or suicide attempts. And upwards more than seventy-five percent of people, and in some studies, ninety to ninety-five percent of people who meet criteria for borderline personality disorder engage in self-injury, um, or have made more than one suicide attempt in their lives. And this tells us a couple of things. Um, one is that they're, that, that on its own is considered a very high-risk behavior because people who engage in self-injury, even if they don't intend to die, there could be accidental death as a result of self-injury.

   27. PAPeter Attia33:29

       What, what are some examples? I mean, people probably think of the most common examples of people cutting themselves or burning themselves. What, what are some-

   28. SRShireen Rizvi33:36

       Yeah

   29. PAPeter Attia33:36

       ... other examples of, of self-injurious behavior that people engage in?

   30. SRShireen Rizvi33:40

       Um, headbanging, uh, or, um, punching or hitting oneself. There are f- multiple forms of, of cutting, um, that include, you know, different objects to cut, but could also be people, um, really intensely scratching themselves to the point where they, uh, draw blood. There's overdosing is considered-
6. 38:15 – 49:04

   How work with suicidal patients led to the development of DBT—a dialectic between change and acceptance

   1. PAPeter Attia38:16

      So let's go back to Marsha and her journey.

   2. SRShireen Rizvi38:18

      Mm.

   3. PAPeter Attia38:18

      So she has this, you know, literally come to Jesus, right? So she has this kind of epiphany in her late teens or early twenties, um, which it sounds like, you know, puts her on a different path, potentially saves her life.

   4. SRShireen Rizvi38:33

      Mm-hmm.

   5. PAPeter Attia38:33

      It's still a long way from there to where we are today. So walk us through that journey.

   6. SRShireen Rizvi38:41

      Right. So this is where it picks up in terms of the story that, um, is part of the, the, the development of DBT's story. So, um, now leaving out her own personal history, you know, Marsha went on to get a degree in... I mean, I should also point out that I think one of the factors that led to Marsha being able to do this is that I think she's hands down a genius. Uh, and so that was probably, um, uh, despite her really difficult, um, experiences, she had this amazing capacity for, you know, thought, uh, that helped her, I'm sure, in numerous ways, including, um, developing this treatment. But so she went on to get a degree in, in social psychology, a social psychology PhD, um, which is a little known fact about her, that she's not a clin- she doesn't have a degree in clinical psychology, but she got her social psychology degree, but then decided that she wanted to get clinical training, and that's what led her to this, um, training experience at Stony Brook, which is where they were, um, uh, doing a lot of work, um, on theory and treatment related to cognitive behavioral treatments for a range of disorders. And at that time, nobody was studying cognitive behavioral treatment for suicidal populations. And so Marsha decided, "I wanna take what we know about CBT that seems to be hugely effective for all of these disorders, and I wanna take all that we know about CBT and just plop it into treating, um, chronically suicidal individuals." The way she reports it is saying she wasn't interested at that time in diagnosis. She just wanted to work with people who chronically experienced, um, urges to die. And so that's what she attempted to do, and by her accounts, um, this quickly blew up.

   7. PAPeter Attia40:45

      And, and just for-

   8. SRShireen Rizvi40:46

      Because-

   9. PAPeter Attia40:46

      Just for timing, this is kind of-

   10. SRShireen Rizvi40:47

       Yeah

   11. PAPeter Attia40:47

       ... 'cause I'm guessing this is now the early '80s?

   12. SRShireen Rizvi40:50

       Yes.

   13. PAPeter Attia40:51

       Okay.

   14. SRShireen Rizvi40:51

       Late '70s, early '80s, when she did her fellowship there.

   15. PAPeter Attia40:56

       And do we have a sense of how she is treating herself at this point? In other words, how is she regulating her own emotions? Are the tools of CBT things that she is finding helpful for her own self-care?

   16. SRShireen Rizvi41:11

       This is a great question, and I'm not sure I, I know what the answer is. And what's interesting is that it's, it's, um, I think that what Marsha did was she took a lot of her own experiences, and then she was able to translate that into cognitive behavioral terms, whether sh- and, and which led to the development of a lot of the skills in the, in DBT that she developed, um, for people. Whether she was, um, thinking at the time about applying CBT to herself, I don't know, but I think that that's, uh, what she ended up doing-

   17. PAPeter Attia41:46

       Yeah, yeah

   18. SRShireen Rizvi41:47

       ... by developing these, these skills.

   19. PAPeter Attia41:48

       Sh- so she sort of became the index case, right?

   20. SRShireen Rizvi41:51

       [laughs]

   21. PAPeter Attia41:51

       You know, she was sort of w- uh, not necessarily thinking it th- of this way, but she was working out the tools of how do you transition... You know, I, I sort of liken that to what Bruce Lee did. I don't know how familiar you are with Bruce Lee, but, you know, um, you know, i- i- most people sort of know him as, you know, kind of a movie star in martial arts, but, but he was far more relevant in creating a system of martial arts called Jeet Kune Do, which-

   22. SRShireen Rizvi42:15

       Mm

   23. PAPeter Attia42:15

       ... took from over 30 different other styles of martial arts and, and in his words, "Took what was useful and discarded what was useless," and sort of created a new system with a very particular goal, by the way. So he had a very clear objective in what Jeet Kune Do was to be about. Um, and it, it, in some ways, it's almost like that's what Marsha was doing on herself, right?

   24. SRShireen Rizvi42:42

       Yes, on herself, and also in her treatment development work-

   25. PAPeter Attia42:47

       Yeah

   26. SRShireen Rizvi42:47

       ... which is, you know, a very iterative process. Like, "Let me try this. Does this work? I'll keep it."

   27. PAPeter Attia42:53

       Yep.

   28. SRShireen Rizvi42:53

       "Does it not work?"

   29. PAPeter Attia42:54

       Just get rid of it.

   30. SRShireen Rizvi42:54

       "I'll throw it out."
7. 49:04 – 56:29

   Details of DBT: defining the term “dialectical” and how to access the “wise mind”

   1. PAPeter Attia49:04

      So this is probably a great time to double-click on what dialectical means because it is I don't know. I, I, I'm not sure if it's innate to us, right? I, I think it requires some practice.

   2. SRShireen Rizvi49:17

      Yeah, I was listening to some interview the other day where somebody just simply said, "Humans don't like contradiction." [laughs]

   3. PAPeter Attia49:24

      Mm-hmm.

   4. SRShireen Rizvi49:24

      And I think that that's true. We don't like contradiction, and so dialectics is really the, um... at least I'm... By the way, I'm no expert in dialectical philosophy as, you know, as Marx, um, initially wrote about it. I'm, I'm more a student of dialectics as it informs, you know, my life and my practice. But, uh, dialectics is this understanding that there is contradiction and opposition and tension in everything. Uh, and therefore, we can't avoid it. Um, and the more we try to avoid conflict and tension, um, the more likely it is that we're going to see conflict and tension. Uh, and so dialectics is, at least, again, in the practice of DBT, is the practice of recognizing tensions as they exist, polarization as it comes up, and then striving to find, um, what is valid about both sides, or both sides of the tension, and seeking to find a synthesis, some new argument or new statement that recognizes, um, and adopts the validity in the two opposing sides.

   5. PAPeter Attia50:47

      This might be a, a reasonable time to jump forward, and then I wanna come back 'cause I love this-

   6. SRShireen Rizvi50:51

      Mm-hmm

   7. PAPeter Attia50:51

      ... sort of story. But if you've, if a person listening to this or watching this has ever kind of gone through DBT, then they're familiar with the workbook, right? You, you're doing this in a very structured way, and one of the first images in the workbook is the two intersecting circles of wise mind and emotional mind. Do you-

   8. SRShireen Rizvi51:10

      Emotional mind and reasonable mind.

   9. PAPeter Attia51:11

      Sorry, reasonable mind. Yeah, wise mind being the intersection.

   10. SRShireen Rizvi51:13

       With di- with...

   11. PAPeter Attia51:13

       Yeah.

   12. SRShireen Rizvi51:13

       Yeah.

   13. PAPeter Attia51:14

       So, um, m- maybe use... You wanna... Can we use that as an example of dialectical synthesis, where you have those two minds, uh, intersecting, and then that, that union or intersection of them being the wise mind, and how do we find those? But, but again, contrasting it with, with, uh, sort of emotional and, and reasonable mind.

   14. SRShireen Rizvi51:33

       Yeah, so I think you, um, that's exactly right. That that is an illustration, a key illustration of dialectics at play is this, is this notion of wise mind, and the way we... and wise mind being a skill in the workbook that we teach people as something that we, um, are striving to, uh, to access wise mind more often in our lives, and that, that accessing wise mind involves synthesizing these, these two tensions potentially, or polarizations known as emotion mind and reasonable mind. So we, um... emotion mind is the idea that a state in which we are completely controlled by our emotions. Uh, so when we're angry, it could be lashing out at somebody. It could be engaging in physical violence. It could be threatening physical violence. It could be slamming doors. Uh, it could be quitting things. You know, all the things that we might do when we're, when we're being controlled by the anger we're experiencing. Reasonable mind, on the other hand, is when we're controlled kind of by facts and logic, and emotions aren't really, um, uh, we're not aware of or experiencing any strong emotion. And you could, you could imagine, or you can envision the tension that exists between these two if you've ever been in emotion mind having an argument with somebody in [laughs] reasonable mind, uh, or vice versa because, um, that happens a lot. I think it has happened in my marriage. It probably happens a lot, uh, across many people's marriages, where one person is in emotion mind, the other person is in reasonable mind, and that's a recipe for, uh, you know, really strong conflict. So wise mind is saying, "Okay, what can I, um... what's valid about the emotion that I'm experiencing here? Uh, what's valid about reasonable mind that I'm experiencing here, and what's a synthesis?" So a silly story that we might tell to illustrate a wise mind or emotion mind is, uh, you're walking down the street, and you pass by a pet store, and in the window are a dozen puppies.

   15. PAPeter Attia54:04

       [laughs]

   16. SRShireen Rizvi54:05

       Or if you're a cat person, imagine a dozen kittens, okay? Uh, emotion mind takes over and says-

   17. PAPeter Attia54:14

       Get them all

   18. SRShireen Rizvi54:15

       ... "I want all the puppies."

   19. PAPeter Attia54:17

       Mm-hmm.

   20. SRShireen Rizvi54:17

       Every single one of them because this one is cute for this reason. This one is cute for this other reason. Oh my God, they would be so happy together, and I would be so happy if I had all these puppies in my life. I want them. So emotion mind says, "Get all the puppies." Reasonable mind says, "Oh my gosh, dogs are so much work. You have to walk them three times a day. They're expensive. You have to get all this equipment. Uh, you have to get a veterinarian. You have to, uh, restructure your time so that you spend more time with the dogs or not. You have to, you know, reimagine your whole life around that." So reasonable mind might say, "No puppies." Uh, "Puppies are never for you," right? So what does wise mind say? Well, what's great about even teaching this as a, as an idea is that wise mind is not, um, the- Or, and a synthesis, a dialectical synthesis, is not a compromise. It's not a halfway point. Because if I were to say that, then wise mind would say, "Get six of the puppies," if there are 12, right? [laughs] Uh, and that makes no sense, um, as a compromise, uh, or as a synthesis because it's not seeing the validity in both sides. So what would wise mind be? That would vary depending on the person. Because for some people, a wise mind decision would be to bring home a puppy. For other people, a wise mind decision would be to say, "Now is not the right time for me to have a puppy, but I am going to do X, Y, and Z in order to increase the likelihood that I can have a puppy in the future." Um, wise mind might be, "I have the perfect scenario now. I can bring home two puppies, and we will live happily ever after." So it's going to, to vary, but the idea of finding the synthesis is about, um, seeing what's valid and true about both ends of the... or both of the sides and then trying to figure out, um, what a synthesis could be. Does that make sense?

   21. PAPeter Attia56:25

       It does. It, it really does, of course. And, um,

8. 56:29 – 1:09:50

   Practicing mindfulness and radical acceptance in the context of DBT

   1. PAPeter Attia56:29

      I think one of the things I'm struck by when I look at the, the notebook, the workbook that we use in DBT, is how much is in it.

   2. SRShireen Rizvi56:38

      Mm-hmm.

   3. PAPeter Attia56:38

      And to think that this is sort of the work of largely one individual, and obviously it's been iterated on, but it's really kind of remarkable. So can we kind of go back to the story of some of the earliest insights she had treating some of the most in-need patients and how she basically then realized she couldn't do what she was doing under the umbrella of CBT and needed to make this change from the cognitive to the dialectical and create another form of behavioral therapy, which again is... It's really a, a, a, it's really a, a kind of remarkable, um, thing to, to realize given how relatively recent this is. I mean, this is something that's happened in the last 30 or 40 years.

   4. SRShireen Rizvi57:26

      Agreed, yeah. So I think, you know, getting back to where she was in terms of realizing that, you know, "If I push for change too hard, disaster happens. If I push for acceptance too hard, disaster happens. What can I do to, you know, find, um, the middle? How do I balance these two things?" And again, part of the, the lore of the story of DBT was that she was, um, writing about this idea of balancing change and acceptance, and these were the days where she would, you know, write up notes, either handwritten or on a typewriter, and hand them over to a secretary who would, you know, type them up or revise them. And, uh, her story is that the person, her, her assistant that was working on typing this all up, came to her one day and said, "My husband is a graduate student in philosophy, and, uh, we were looking at this, and we think that what you're describing actually is something that he, he studies, uh, and is called dialectics." So according to Marsha, she didn't know anything about dialectical philosophy, um, as she was iterating this treatment, and this was one of those happenstance moments that, um, that came to her. And then, of course, she sought out readings, uh, descriptions of dialectical philosophy and saw, yes, that is exactly what she's thinking, and that dialectical philosophy informs a lot of science, uh, and scientific thought and so, um, actually worked well within the, the paradigm of, you know, the development of, of cognitive behavioral treatments. So, so that's where, you know, DBT started to take form. Howev- if, if you're familiar with her books, you know that her original treatment manual that was published in 1993, uh, including the... and, and also the original skills workbook that was published in 1993, says on the cover cognitive behavioral therapy for borderline personality disorder.

   5. PAPeter Attia59:43

      Oh, I wasn't aware of that.

   6. SRShireen Rizvi59:43

      Yeah.

   7. PAPeter Attia59:43

      Yeah, I wasn't aware of that. Okay.

   8. SRShireen Rizvi59:44

      The, the newer edition says dialectical because she was told at the time by the publishers that nobody will know what this means, and nobody will want it. [smacks lips] Uh, and I think that may be true. It's, it's possible that if it was called dialectical behavior therapy on the cover of the book back then, it would not have, um, actually been as popular as it is now. Now, of course, we can put dialectical behavior therapy on the cover of any book, and, um, and people will see the value in it, but I don't think that was true then.

   9. PAPeter Attia1:00:18

      W- when did she develop kind of her own sort of interest in Zen philosophy and the practice of mindfulness, which also is a very important, um, muscle that one kind of develops as they [smacks lips] move along their DBT journey? Was this something that had been more longstanding with her?

   10. SRShireen Rizvi1:00:39

       So I think that this was, um, all happening around the same time, that she was, uh, her own interest in... You know, Marsha grew up, um, uh, in a Catholic family, identified as a very, uh, religious person, identified as saying that at one point she thought she was, um, going to become a nun. Uh, and so this was a large part of her upbringing when... and also was part of that, uh, spiritual experience that she had personally. But I think she also, uh, realized that, and, and another reason, by the way, that she didn't wanna come public with her story early on is that she didn't want the lesson to be ... oh, if you want to get better, you also have to have a spiritual experience. Instead, what she wanted to figure out was how do I, um, how do I operationalize, for lack of a better word, this spiritual experience so that other people could experience it as well? And so I think that was going on in her mind at the same time that she was, um, interested in her own spiritual development and, um, and learned more about Zen and became a student of Zen Buddhism and saw that they, they all connected and came together because ultimately how she translated that personal experience, um, is into this idea that you mentioned earlier of radical acceptance. Can you radically accept this moment, this situation yourself exactly as it is? And if you can experience that radical and complete and total acceptance, you can experience joy. You can crack open the moment of joy, she would say.

   11. PAPeter Attia1:02:47

       Yeah, I mean, the, the there are some things where, you know, Shireen, that's... I get it, right? Like you're stuck in traffic, right? So you're, you're, you're, you're supposed to be going somewhere, and let's pretend it's someplace that matters, right? You're, it's not-

   12. SRShireen Rizvi1:03:00

       Mm-hmm

   13. PAPeter Attia1:03:00

       ... just like a dinner reservation. Let's say it's your kid's sporting event, or you're going to the airport and it's a flight, and you, if you miss it, it's gonna really wreck things up, and there's nothing you can do about it. You're stuck in traffic. There's an accident a mile ahead, and that this is the way it's going to be. Walk me through what you would say, I mean, you know, your, your, your patient now is in the car, and you're sitting with them in the car, and they're understandably getting very flustered at the situation. Walk me through radical acceptance in that situation. How are you helping that person go through the, you know, can you fix this problem? Are you accepting this problem? Can you cha-... Like, going through all of those layers, uh, for, for that specific type of problem.

   14. SRShireen Rizvi1:03:44

       Yes, and I've been in that problem-

   15. PAPeter Attia1:03:46

       [laughs]

   16. SRShireen Rizvi1:03:46

       ... myself.

   17. PAPeter Attia1:03:47

       We all have.

   18. SRShireen Rizvi1:03:47

       So I-

   19. PAPeter Attia1:03:47

       Yeah

   20. SRShireen Rizvi1:03:47

       ... understand.

   21. PAPeter Attia1:03:48

       Yeah.

   22. SRShireen Rizvi1:03:49

       Yeah. So, you know, um, what I would say as a precursor is that when we're experiencing suffering, however you define that suffering, if you were to look at it more deeply, you would say the vast majority of the time that we're experiencing suffering, it's because we're thinking about something that has already happened, ruminating, um, wishing it hadn't happened, mulling something over, whatever it might be, or you're thinking about something that may happen in the future, and that actually if you just experience this one moment, uh, and let go of the past and the future, that alone might reduce your suffering a ton. But we could say you might experience pain in this moment, 'cause this moment might be painful, but we're not adding on. We're not adding on all of these things that actually increase our suffering. So in this moment, when you are stuck in traffic, you can't undo the decisions that you made that got you to this point, right? Because, of course, we're saying things like, "Oh, if only I had taken this other road," or, "If only I had left 15 minutes early," or we think all these stupid people on the road, if only they had done something different, right? So that's, those are all fantasy thoughts because they're all not reality of this moment. So I would say how do we reduce our suffering in this moment is to say, "I can't change any of that for today in this moment. This is what it is." Um, and what happens, you'll see, actually, I'm holding my palms up right now as I'm talking because I associate holding my palms up with this idea of willingly accepting this moment, which is, uh, this is the moment that I'm in.

   23. PAPeter Attia1:06:00

       Yeah, it's sort of a surrender posture.

   24. SRShireen Rizvi1:06:02

       Yeah. Uh, yeah, in a way. It's the surrendering, willing, this is the moment I'm in, and what happens if I just, just as though it's easy, but what happens if I accept that right now there is nothing I can do to change this, right? Now, I think the other piece to this is, and this is why it's not just about acceptance, because I would say if this is something that happens a lot, right, if you often find yourself in situations, whether it's traffic or some- running late or something like that, then we absolutely wanna figure out how to prevent this from happening as much in the future. But in this moment when you're there, you can't do that.

   25. PAPeter Attia1:06:54

       So in other words, in the moment of crisis, you don't really want to be problem-solving around how can I avoid this the next time?

   26. SRShireen Rizvi1:07:04

       How do I avoid this crisis again in the future? When I'm at a 100 or a 90 of distress, I'm not going to be able to effectively do that.

   27. PAPeter Attia1:07:14

       Now, obviously, so much of what you're saying sounds very familiar to anybody who has practiced mindfulness or Vipassana or one of its derivatives in forms of meditation. Um, we've had a couple of podcasts that have, have sort of gone into that, and Y- y- you know, when y- y... The, the goal of the practice is to help you identify thoughts and to separate you from these thoughts. And so in this individual, I mean, there's probably nothing, as you say, in this exact moment that is particularly unbearable, but the thoughts are unbearable if you're, if you let them go, right? The... Which is, "I'm gonna get to the airport, I'm gonna miss my flight. Then I'm gonna have to wait for another flight, and I'm probably gonna miss that, too, or there's not gonna be a good seat or whatever, and then I'm gonna not get to where I'm going, and maybe the whole trip's gonna da, da, da, da, da." And, and so what is, what do you say to the person who says, "Okay, Shireen, I understand that those thoughts, which are all future, are not happening to me now, and I can just sit here right now in this car, and frankly, I could turn on music and enjoy the music for the moment. But that doesn't change the fact that that's going to happen. It doesn't change the fact that in an hour, I am gonna get to the airport. I am going to have missed my flight." What do you say to the person when they, they acknowledge that, "I could probably take myself down from 100 to 50 by being present in the moment, but will I get back to 100 when I get to the airport, when I realize that I now have to deal with this mess?"

   28. SRShireen Rizvi1:08:50

       Possibly, but that's a new moment now. Now you're in a new moment and a new situation. So part of it depends on, well, what's your, what's your goal? Uh, so when you're experiencing distress in that moment of being stuck in traffic and not having any control about that, what's your goal? If it's to get to the airport in two minutes, sorry, that's not a realistic goal. We're gonna have to let that one go. If it's to problem solve what will happen when you get to the airport, is there something that you can do while you're in the car? You know, possibly. But if your goal is to how do I make this moment more bearable because I can't undo anything, then I think we have some other options available to us, which could be distracting, you know, doing something like music or, or, uh, some other forms of distraction that you could safely do in the context of your car.

9. 1:09:50 – 1:16:15

   Applying “radical acceptance” to tragic scenarios

   1. PAPeter Attia1:09:50

      Okay, so now let's look at kind of the other end of the spectrum where it, I think it becomes even harder to do this. So I'll think of two examples. I think of an individual who receives a terminal diagnosis, so they're, they're diagnosed with a cancer, for example, that, um... And let's, let's make this even more tragic, right? I think anybody dying of cancer is tragic, but now it's someone your age or my age who's, you know, dying decades too soon.

   2. SRShireen Rizvi1:10:16

      Mm-hmm.

   3. PAPeter Attia1:10:16

      Um, but they're basically told, and, and it's accurate, that, "Look, in six months you're not gonna be alive." Um, so in that sense, they're, they're, you know, they're, they're mourning the loss of their life and who they're going to be away from. And then, and then there's another example which is, is very fresh in my mind right now because, um, you know, m- a very close friend of my wife's, uh, daughter drowned, um, a year ago, and, and-

   4. SRShireen Rizvi1:10:42

      Mm

   5. PAPeter Attia1:10:43

      ... because we're coming up to the one-year anniversary of that, it's, it's all, it, you know, she's reliving a lot of this.

   6. SRShireen Rizvi1:10:49

      Mm-hmm.

   7. PAPeter Attia1:10:49

      So, y- you know, I, it's hard for me to imagine what she's going through and what her husband is going through, but they can't, there's no, there's, there's nothing that will undo that there.

   8. SRShireen Rizvi1:11:01

      No.

   9. PAPeter Attia1:11:01

      So, so maybe use those two examples as two of the, the most difficult examples of how can radical acceptance allow, a, this, this person who's, who's gonna die far too soon to come to grips with that and maybe have a chance at having the best six months that they can have versus not, you know, be, you know? And then perhaps even more tragically, the, you know, a parent losing a child is, you would sort of hold that up as about as tragic as, as anything can go, where nothing-

   10. SRShireen Rizvi1:11:36

       Mm-hmm

   11. PAPeter Attia1:11:36

       ... is ever going to bring that child back. Um, and yes, cognitively you can say, "Look, you still have other children, and you have to be a great parent for them. You can't allow yourself to..." You know, you can go through all of that stuff. But, like, I don't know how I would cope with that. I don't think I could. I'm not, I'm not sure. So yeah. N- now let's go from the sort of banal of traffic to the, the really heavy stuff of life.

   12. SRShireen Rizvi1:12:02

       Yeah. Easy, right?

   13. PAPeter Attia1:12:03

       Mm-hmm.

   14. SRShireen Rizvi1:12:04

       So, uh, I mean, one, I've thought about both of these things, um, a lot or both of these circumstances a lot, and I think, uh, one of the, um, misunderstandings about acceptance is, uh, somehow this idea that i- if you accept something, you don't experience pain.

   15. PAPeter Attia1:12:26

       Hmm.

   16. SRShireen Rizvi1:12:27

       And so I wanna differentiate that, uh, life is full of pain. No matter how zen and mindful you are, you're going to experience, uh, pain and a lot of pain, and we're not trying to eradicate pain because actually without pain, um, and I don't mean, you know, physical pain, I mean emotional pain, but it could be both, but without that, we would have other problems, right? If we did not experience, um, pain as you hear about your friend's daughter, that would be a problem for you in a different way. So we need to understand that that pain is going to be a part of our lives, and actually we cause a lot of problems for ourselves when we try to escape the experience of pain. So that's one thing about, um, reality, radical acceptance that I wanna talk about. But the other is when, when you ask questions like that, like how can we ask somebody to radically accept this, I would answer in part by saying, what's the alternative?

   17. PAPeter Attia1:13:33

       Hmm.

   18. SRShireen Rizvi1:13:34

       The alternative is refusing to accept. How d- how does that work? [laughs] How, how do you do that? Um, how, and how long can you sustain that for? So I would actually argue that the refusal to accept or the putting your head in the sand or the denying reality actually ends up taking a lot more re- mental resource and ultimately causing more problems for you in the long run. And that said, from a DBT perspective, when we, when we talk about practicing the skill of radical acceptance, we have another expression called turning the mind, which is referring to the fact that, um, practicing radical acceptance involves a very active process of continuously turning your mind towards acceptance. The, the metaphor is that you're at a fork in the road, and one road is acceptance and another road is, is refusal to accept. You're gonna come across the fork in the road possibly multiple times a minute, and what does it look like for you to say, "I'm gonna actively and willingly choose the road of radical acceptance. How can I turn my mind, my body, my soul towards acceptance?" And for me, a lot of it is actually asking myself that question of what's the alternative? What other choices do I have? Um, and recognizing that more suffering comes from refusing to accept, um, more often.

   19. PAPeter Attia1:15:13

       The, the fact that it's referred to as radical acceptance versus acceptance I, I think kind of highlights that, that it, it's not easy. It's not, it's not a decision. It- it's not like you would sit down with my wife's friend, have this discussion once, say, "What's the alternative? I know this is awful, but in the long run, this is going to produce more happiness for you and your family." And for her to say, "Yep, I think that's right. Thanks."

   20. SRShireen Rizvi1:15:37

       [laughs] Mm-hmm.

   21. PAPeter Attia1:15:38

       [laughs] Like, I- it's o- no, it's not. It's to your point, every minute of every day for God knows how many months and years, you're confronted with that. And if I speak for myself, there's a lot of, uh, what's the, what's the term? Uh, uh, backsliding, right?

   22. SRShireen Rizvi1:15:57

       Mm-hmm, mm-hmm.

   23. PAPeter Attia1:15:57

       There's a lot of, "No, I don't want to accept this today."

   24. SRShireen Rizvi1:16:00

       Mm-hmm.

   25. PAPeter Attia1:16:00

       Like, I, I'm not... I don't accept this. This is, I'm angry about this. I want to pout and have a little pity party about this. Um-

   26. SRShireen Rizvi1:16:06

       Mm-hmm

   27. PAPeter Attia1:16:07

       ... and then maybe w- I experienced that, and I realized that wasn't very productive because now I feel actually worse. And so-

   28. SRShireen Rizvi1:16:14

       Mm-hmm

   29. PAPeter Attia1:16:14

       ...

10. 1:16:15 – 1:23:30

    The five domains of skills taught in DBT

    1. PAPeter Attia1:16:16

       um, you know, one of the things about DBT that I... So I, I, you know, we were introduced through Andy White, which is who I work with, and I just, I just think the world of Andy. O- one of the things about DBT that for me makes it a wonderful system is that you do work. Like, you, you have... You, you, you write. You do, you have homework. You, you, you have to talk, you know, write out your emotions and your decisions and the, the, the trees. Like h- you know, if you feel this, do you do this? And I don't know. I th- how deliberate was that in, in Marsha's mind as a system? I've never done CBT, so I don't know if CBT-

    2. SRShireen Rizvi1:16:54

       Mm-hmm

    3. PAPeter Attia1:16:54

       ... has a similar workbook, and she's just modifying it. Um, is that, is that something that's been modified from other systems?

    4. SRShireen Rizvi1:17:01

       Certainly CBT is associated with doing homework-

    5. PAPeter Attia1:17:05

       Mm-hmm

    6. SRShireen Rizvi1:17:05

       ... doing work in between sessions. Um, uh, more standard cognitive therapy is associated with doing worksheets about your thoughts.

    7. PAPeter Attia1:17:15

       Hmm.

    8. SRShireen Rizvi1:17:16

       What thoughts you have, what the evidence for your thoughts are, that sort of thing. And so I think doing work, doing worksheets, not shying away from the term homework, uh, as part of the treatment is very consistent with the CBT model. Now, the, what I will say is, um, [lips smack] you just reminded me about this based on something you said, is that one of the, um, assumptions about borderline personality disorder from the DBT lens is that this is, uh, uh, we use a skills deficit model, which is to say that we believe that people who end up with the constellation of problems associated with borderline personality disorder have an absence of certain skills and skillful behavior in their lives, and that absence could be a result of never having been taught it in the first place or having had effective behaviors been punished out of them by their environment. This is the environmental piece that we're talking about. But they d- they don't have, um, we all, you know, have certain deficits in, in some are- in some skillful areas. And so the work that you're referring to-

    9. PAPeter Attia1:18:32

       A- and another one I would just add to that, it's-

    10. SRShireen Rizvi1:18:34

        Yeah

    11. PAPeter Attia1:18:34

        ... so, so yeah, it's the, the skills have never been modeled for you. You've done them correctly and been punished for them. I think a bigger one might be you've done them incorrectly and never been corrected.

    12. SRShireen Rizvi1:18:46

        Yeah, that's a good one, too. Yeah, absolutely.

    13. PAPeter Attia1:18:48

        So you've built all the muscle memory doing it wrong your whole life, and you didn't have parents there to sort of say, "Hey, that's not how you do it. This, do it this way."

    14. SRShireen Rizvi1:18:59

        Right.

    15. PAPeter Attia1:18:59

        Yeah.

    16. SRShireen Rizvi1:19:00

        And it's a lot harder to unlearn a behavior than it is to learn a new behavior, uh, and that we know that as a phenomenon. So, so Marsha developed this, you know, this workbook, what we refer to as the skills training manual, that's part of, of the treatment of DBT and perhaps what DBT is probably most known for, more broadly speaking, are the skills, um, that are part of it, but that these, um, skills deficits are thought to exist in, in four different domains or five different domains, actually. Uh, mindfulness, um, so when we say someone has a deficit in mindfulness, it's not that we're referring to anybody who doesn't practice Zen as having an, a mi- a mindfulness deficit, but it's a deficit in, excuse me, a deficit in, um Uh, the capacity to be aware of the present moment, basically. Um, another domain, uh, in which people have deficits is interpersonal effectiveness. Um, as I go through this, you'll see everybody has deficits in, in all of these areas at different times, and I think again, that's, that's part of the beauty of DBT, is that it can help so many people. So interpersonal effectiveness, which could mean conflict with others, but also could mean deficits in, in knowing how to ask for something effectively, how to say no effectively. Uh, emotion regulation deficits is the third domain. So, uh, deficits in knowing how to label your emotions, what to do with emotions when you have them, how to prevent having intense and extreme emotions, how to change emotions. Can't remember if I said that. Uh, and then a fourth domain is, is deficits in distress tolerance. How do you tolerate really stressful and distressing situations without doing anything that, to make the situation worse? And then the fifth area, um, that is not talked about as much, though I can certainly talk about it if that'd be helpful, is this idea of self-management, deficits in self-management, which has to do with, um, being able to do things you don't wanna do [chuckles] , you know, broadly speaking. You know, how some people can get up every morning at six o'clock and go exercise and eat a healthy breakfast, uh, and, you know, go to work while other people snooze their alarm eight to 12 times.

    17. PAPeter Attia1:21:25

        [chuckles]

    18. SRShireen Rizvi1:21:25

        You know, haphazardly eat breakfast sometimes, um, get to work late. You know, those are sorts of things that we might f- uh, say fall into this kind of self-management domain. And so DBT is designed as a treatment package to teach people the skills to overcome deficits in these different domains.

    19. PAPeter Attia1:21:47

        Uh, so I actually wasn't aware of the fifth. I was really only aware of the four.

    20. SRShireen Rizvi1:21:51

        Mm-hmm.

    21. PAPeter Attia1:21:51

        Is that fifth one, um, a- is it kind of a more recent addition?

    22. SRShireen Rizvi1:21:57

        So it actually is in the original treatment manual in the 1993, um, text that she put out, but her thinking was, "I don't need to create a whole other skills module for self-management because DBT therapists are going to infuse this throughout their entire treatment." And I think this might have been at the time a little bit of a missed opportunity because I don't think she realized that actually a lot of clinicians don't know how to do that, um, very well. Marsha was thinking that actually this is where behaviorism comes in. It's teaching people principles of, of behaviorism. So you don't see it in the original skills manual, and you don't necessarily see it in the new skills manual, or what I refer to [chuckles] as the new skills manual, unless you look, because where you would see it now is in the set of skills that are referred to as the walking the middle path skills.

    23. PAPeter Attia1:22:48

        Mm.

    24. SRShireen Rizvi1:22:49

        Which are, which actually came out of, um, the first adaptation of DBT for adolescents and their families. Um, and Jill Rathus and Alec Miller, who, uh, along with Marsha created the adolescent version of DBT, uh, took a lot of these principles of the self-management skills and created this fifth module of DBT skills called walking the middle path in which they teach adolescents and their caregivers, their parents, these skills about how to, how to manage your behaviors, how to learn behaviors, um, and to be more effective more broadly.

11. 1:23:30 – 1:26:15

    Why Marsha chose borderline personality disorder as her focus when developing DBT

    1. PAPeter Attia1:23:30

       Y- you know, just kind of going back to the origin of DBT around basically, um, a modified tool to help some of the people who are suffering the absolute most, right? If you think somewhere in the back of Marsha's mind, it probably wasn't just, "How do I make CBT better to handle the most recalcitrant depression, suicidal patients?" Perhaps on some level it was also BPD, right? Which we didn't... We kinda glossed over this, but I'm guessing that CBT has historically not been very successful for borderline personality disorder. Is that a fair statement?

    2. SRShireen Rizvi1:24:09

       Well, I would say at the time that Marsha was, was doing this treatment development, we didn't know. Um-

    3. PAPeter Attia1:24:16

       Mm-hmm

    4. SRShireen Rizvi1:24:16

       ... and, uh, I think the, the general thought, and there actually, there have been more studies that have looked at whether the presence of borderline personality disorder interfered with, um, outcomes for standard CBT, and there's kinda mixed data on that in that some studies show that the presence of BPD did, uh, lead to worse outcomes in, in some studies. But what I was going to say is that Marsha didn't know when... The reason that she gives for her pivot to borderline personality disorder as a population of interest is that when she was first seeking research dollars, research grants to study the development of DBT and the, you know, to start to do randomized clinical trials of B- of DBT rather, back in those days you could only get research grants from NIH if you identified a disorder of interest.

    5. PAPeter Attia1:25:20

       Mm-hmm.

    6. SRShireen Rizvi1:25:20

       The way she tells it as oversimplified is that, you know, she was interested in suicide and suicidal behaviors, and at the time she thought her choices based on that behavior was either depression or BPD. And she said at the time she didn't wanna do depression because there were already so many, um, smart people doing depression research. She wanted to do, uh, go into an area where there weren't already a lot of people doing research in this area, and that's why she chose BPD. Again, this is the story, but of course I think there's more to it than that because I think the, you know, her own experiences, uh, would lead one to assume that she also had specific interest in the emotion dysregulation piece that goes along with BPD and doesn't necessarily go along with, with more standard depression.

12. 1:26:15 – 1:31:50

    Is there any benefit in doing DBT for someone without a pathological condition?

    1. PAPeter Attia1:26:16

       Yeah, I mean, what, so what would you say... I know what I would say, but what would you say to somebody who doesn't have BPD, doesn't, is not depressed, who says, "You know, Peter, Shireen, this is all very interesting, but what... Would there ever be any benefit in me doing DBT, given that this program was really built around people with real pathology, of which I have none? If you... I went through the DSM 5 last week. Nothing in there. I don't meet the criteria for anything fully. Um, would I have any, would, would there be any value to me in, in this, uh, type of practice?"

    2. SRShireen Rizvi1:26:52

       I think that's part of what's so fascinating about this treatment, because you're exactly right. This was the treatment that was developed for what could have been termed the worst of the worst at the, at the time, and it's a treatment that is actually for all of us. I have yet to meet a person who could not benefit from at least learning some of the skills, nor have I met a person who, uh, I've yet to meet a person who, uh, hasn't identified the skills as being something that could be relevant for them. Now, whether they're always willing to use them or apply them or want to do them, that's a different issue, but when I talk about, "Here's what the skills are for," I get universal agreement that those skills could be useful to learn.

    3. PAPeter Attia1:27:44

       Yeah, the way I kind of describe it, I, I... You don't know this about me, but I love cars and race cars and all sorts of things like that, and a lot of people say, like, "I don't really understand how there's any value in, you know, a company like Mercedes or, you know, any of these companies participating in, you know, building race cars. You know, it's such an expensive proposition. It seems so gratuitous." Um, but the trickle-down effect for what the impact of that is on street cars is remarkable in terms of fuel efficiency, power, safety, all of these things. You know, it's true. If you want to build a Formula 1 car, it's, you know, it's basically a $400 million a year operation to build and operate those things, but those things are functioning at the absolute limit, and if you... You know, where every gram matters, and the stakes are so high, and if you take everything that you learn there and bring it down to the rest of us who aren't driving Formula 1 cars, the benefit is actually enormous.

    4. SRShireen Rizvi1:28:45

       Mm-hmm.

    5. PAPeter Attia1:28:45

       And I think of it as sort of similar, right? Which is this is a system that was conceived and, um, validated on a sample set of people with real difficulties in regulating their emotions. And, you know, when I go through the list of the DBT, you know, skills pillars, it's like, I mean, check, check, check, check, check, right? I mean, I can... I might not meet the diagnostic criteria for something in the DSM 5, but, I mean, I have enormous problems with all of these things. I have staggering deficits of skills. I mean, one of the first exercises that really illustrated that was something as simple as identification of emotion.

    6. SRShireen Rizvi1:29:25

       Mm-hmm.

    7. PAPeter Attia1:29:26

       Y- you know, it was any emotion that-

    8. SRShireen Rizvi1:29:28

       I wouldn't say that that's simple necessarily.

    9. PAPeter Attia1:29:31

       Y- yeah, yeah, yeah.

    10. SRShireen Rizvi1:29:31

        Yes. [laughs]

    11. PAPeter Attia1:29:32

        But, but it was, like, I couldn't really identify an emotion that wasn't anger. It was very difficult-

    12. SRShireen Rizvi1:29:37

        Mm

    13. PAPeter Attia1:29:37

        ... to go beyond anger to helplessness, sadness, hurt, fear, all of these other things. So that, I mean, I don't know, Andy and I must have spent three months with my homework just being, "Okay, you're gonna get angry 16 times a day. 16 times a day, pull out this sheet and go through and figure out what else is going on." You know, that's, that sounds maybe simple, but that's learning a new language as well.

    14. SRShireen Rizvi1:30:06

        Mm-hmm. What, what made you want to do that? Why not just stick with your experience of anger?

    15. PAPeter Attia1:30:12

        Yeah, I mean, look, it's, it's a, it's exactly what you said earlier. It's like what's the alternative? Well, the alternative is you're really, you know, alienating a lot of people. Um, and I think watching my kids get older and realizing I don't want them to see me always angry. I mean, uh, you know, I think I was just angry 24/7. I don't think I really experienced anything that wasn't anger. Um, so yeah, I think it was just, uh, it was, it was sort of just saying, like, I have to sort of break this cycle because it's... You know, my kids will... If every time I get cut off on the road, I'm screaming so much at the person who cut me off that you can see the droplets of my spit on the windshield, even if I'm not yelling at them, it's not like I was actually yelling at my kids. But it doesn't ma- I don't... You know, as I've learned since, I don't think kids can appreciate the difference. A five-year-old doesn't understand that just because Daddy is yelling at the guy that cut him off, he's not mad at me. I, so I think once I came to realize that, I realized, "No, this, I, I don't wanna do this."

    16. SRShireen Rizvi1:31:22

        Yeah, I think these skills are for... I just totally agree. I mean, I've been... So I, I don't actually have my own experiences with borderline personality disorder or, uh, psychopathology in that way, and I learned DBT as a grad student, uh, in, you know, my early 20s, and it's been a long time now that I've been using and applying

13. 1:31:50 – 1:44:44

    The DEAR MAN skill of DBT

    1. SRShireen Rizvi1:31:50

       DBT, and I will still go in my head, like, when I have a difficult interpersonal situation happening where I will walk through the steps in my mind of the, the DEAR MAN skill of how to ask for something and be effective.

    2. PAPeter Attia1:32:04

       Let, let's go through DEAR MAN in a moment. Finish your story-

    3. SRShireen Rizvi1:32:07

       Yeah

    4. PAPeter Attia1:32:07

       ... but I would love to go through it.

    5. SRShireen Rizvi1:32:07

       Well, I was just gonna say-

    6. PAPeter Attia1:32:08

       Yeah

    7. SRShireen Rizvi1:32:08

       ... like, it's been 25 years, and I'll still be writing an email, and then I'll say, "Wait. Pause. Edit. Am I following the D-E-A-R structure? What, what can I take out? What am I adding on? What judgments are in here?" So I feel like I, you know, I've been a pretty skillful person for most of my life, and I still Need to... I still benefit from actively thinking about, uh, using these skills in my daily life

    8. PAPeter Attia1:32:41

       So, I mean, I'm still so early in my journey. I would say I'm, you know, if, if, if, if 10 out of 10 is having all the skills and always employing them, one out of 10 is not even knowing what a skill is. You know, I, I'm in the sort of three to four out of 10 range, which is I know them and, I don't know, uh, maybe half the time I reach for them correctly. Um, but let's talk about DEAR MAN, um-

    9. SRShireen Rizvi1:33:10

       Mm-hmm

    10. PAPeter Attia1:33:10

        ... because everything in DBT is really built around being highly accessible. It's not, it's not really... At least to me, it doesn't come across as having errors, right? Like, this is-

    11. SRShireen Rizvi1:33:22

        Mm-hmm

    12. PAPeter Attia1:33:22

        ... you know, it's, it's funny acronyms. It's, like, little diagrams. It's... There's nobody that can't do this, right? So, um, tell, tell everybody what DEAR MAN is and, uh, what the acronym is, is really used to walk you through as a, as a thought process.

    13. SRShireen Rizvi1:33:42

        Right. I think sometimes people actually have a negative reaction to all the acronyms in, in DBT, and I think that's a fair criticism, but acronyms are, you know, meant as mnemonics to-

    14. PAPeter Attia1:33:52

        Yeah

    15. SRShireen Rizvi1:33:52

        ... help us remember, um, things that-

    16. PAPeter Attia1:33:54

        Maybe because I went to medical school, we just-

    17. SRShireen Rizvi1:33:56

        We're used to it

    18. PAPeter Attia1:33:56

        ... you do so much through that. Yeah, yeah, yeah.

    19. SRShireen Rizvi1:33:59

        Yeah, though I will say I was training DBT somewhere. Where was it? I think it was Iceland. Was it Iceland? Where they don't do acronyms. Um, like, it's just not part of their language-

    20. PAPeter Attia1:34:08

        Mm

    21. SRShireen Rizvi1:34:09

        ... uh, to use acronyms, and so that-

    22. PAPeter Attia1:34:10

        [laughs]

    23. SRShireen Rizvi1:34:10

        ... is an added difficulty. But in, in [laughs] the US and Canada, and we can talk about these acronyms. So DEAR MAN is a skill that's in the interpersonal effectiveness module. So this, these are the skills that are designed to help you be more effective with other people in your life. And DEAR MAN is [clears throat] specifically the skill to, uh, on how to ask for something in a way that gets another person to give it to you, or how to say no to something in a way that gets the other person to accept your no, or increases the likelihood, I should say, because nothing is going to be 100% effective. So DEAR MAN walks you through these seven kind of sub-skills to help you do that. So it stands for describe, express, assert, reinforce. That's the, the D-E-A-R part. That's, that's basically what you say, um, or write, uh, to ask for something. And then the MAN stands for mindful, appear confident, and negotiate, or be willing to negotiate. So that when you're in a situation... So I don't know, do you have a situation that is coming up for you where you need to ask for something or say no to something?

    24. PAPeter Attia1:35:33

        Yeah, I do actually. Um, I don't think I can talk about it publicly, unfortunately.

    25. SRShireen Rizvi1:35:39

        [laughs]

    26. PAPeter Attia1:35:39

        It's s- such... It's a very good one, but I probably can't talk about it publicly. Let me think of one where I could, um, um, without embarrassing someone.

    27. SRShireen Rizvi1:35:49

        [laughs]

    28. PAPeter Attia1:35:50

        Uh, okay. Now this is gonna embarrass the hell out of her, but let's try it. Um, my daughter wants to get a third earring. So she's got two piercings in her ears, and she really wants to now get a third, and I'm not sure... Maybe this isn't a great example, but I'm hoping to talk her out of it for a little longer. How's that?

    29. SRShireen Rizvi1:36:07

        Mm-hmm.

    30. PAPeter Attia1:36:07

        I, I, I'm like-
14. 1:44:44 – 1:47:55

    Adapting DBT skills for adolescents and families

    1. PAPeter Attia1:44:45

       Uh, I, I think that that's the other... I, I assume that that also factors into the DBT for adolescents, which I actually haven't, uh, maybe it's time that I sort of look at that as well. But I, I haven't really spent any time looking at that work. But I would imagine that it's as much about helping the kids as showing the kids how the parents can change as well.

    2. SRShireen Rizvi1:45:05

       Well, what, what is an amazing adaptation for DBT, so in standard DBT for adults, uh, in, uh, what we do, we haven't really explained, like, what the therapy looks like. But in general what would happen if somebody were receiving DBT treatment is that they would be coming to a skills training group once a week or receiving skills training individually where they meet with a therapist who teaches them these specific skills. They practice it, they come back, report on their practice, um, and get feedback and coaching, et cetera. In skills training group, you might have a number of adults all together, and you teach them all together, and you assign homework, and you all talk about the practice and use of skills. What was an amazing, I mean, I just think it's so brilliant adaptation for DBT for adolescents is that y- in your skills group you have now multi- they're called multi-family skills groups where you have the adolescents in the skills groups, but you also have the adolescent, adolescent's parents or caretakers-

    3. PAPeter Attia1:46:08

       Mm

    4. SRShireen Rizvi1:46:08

       ... in the skills group at the same time, and everybody is learning the skills all together. And the way these groups are designed, it's not oh, we're all learning these skills so that you all can, you know, help your adolescent apply them. Of course, that's part of it. But we're framing the groups as saying, "We're teaching everybody the skills because the parents need the skills as much as the adolescents need the skills." And therefore, the parents have, and caregivers, have to practice the skills the, on themselves, not just for their adolescents.

    5. PAPeter Attia1:46:42

       I mean, do you, do you, do you find it's, do you find it's harder for the parents because, uh... You know, you said something earlier which I completely agree with. It would almost be easier to come to DBT with no skills, positive or negative, and then just learn the positive skills. Um, it's, it's harder to come in when you have decades of reinforced negative skills, anti-skills. [laughs]

    6. SRShireen Rizvi1:47:07

       Mm-hmm. Mm-hmm.

    7. PAPeter Attia1:47:08

       And you have to unlearn anti-skills and then build positive skills. So d- do you see that it's easier for the kids sometimes to pick this up than their parents?

    8. SRShireen Rizvi1:47:18

       I think there's, um, sometimes easier to pick up, but there's different levels of willingness [laughs] and willfulness.

    9. PAPeter Attia1:47:28

       Yeah, fair point.

    10. SRShireen Rizvi1:47:28

        So with adolescents, a lot of the times adolescents, not always-

    11. PAPeter Attia1:47:31

        They're not necessarily there by choice I'm guessing sometimes.

    12. SRShireen Rizvi1:47:34

        Yes. So a lot of the times it's their parents or their schools that say they have to do this. And so there's always a question of how much they're there because they, um, want to be there. Adolesc- I mean, of course, with adults in certain contexts and situations, they don't want there, to be there easy, uh, either. But there's generally more willingness. Um...

15. 1:47:55 – 2:01:19

    Identifying vulnerability factors, increasing distress tolerance, and the impact of physical pain

    1. PAPeter Attia1:47:55

       Let's talk about the structure of the therapy. I, I've jumped around a lot 'cause there's just so many interesting frameworks, and I wanna make sure we get to them. But, um, l- let's assume that y- you know, a, a person comes to you now, um, and they're there by their own choice. This is an adult. And they, they don't meet the criteria for any of the DSM-5s, so this is just someone who's having difficulty interpersonally. Um, you know, one of the things that I think I sort of realized was so much dysregulation stems from interpersonal interactions gone bad with your spouse, with your child, with your coworker, with the person who cuts you off on the street. I mean, it's generally an interpersonal interaction that doesn't meet your expectations, whether those are reasonable or not reasonable, that then leads to sort of an emotional regulation or dysregulation, thoughts that then feed into those emotional dysregulations, and then you create this awful feed forward loop that can lead to bad behaviors. I mean, that... Is that sort of a safe way to talk about it from interpersonal to thoughts, uh, emot- emotions, thoughts feeding off each other and then behaviors? I mean, that's kind of like the pathway of how this all seems to go wrong for people. And I mean, there are s- some people out there who just I seem, who, who seem just w- wonderful, and they don't seem to suffer from these issues. But, but most people, if we're being really honest with ourselves, even if you're not as extreme as, as me, I think most people realize that this isn't always going well. Um-

    2. SRShireen Rizvi1:49:27

       Mm-hmm

    3. PAPeter Attia1:49:27

       ... especially as we're under more external stress. You know, there are... I, I love the idea of distress tolerance, um, and I, I think that's just one of the most interesting concepts is a window, and that's the sort of image that I have of it, right? So I mean, this entire year my distress tolerance window is about this thick.

    4. SRShireen Rizvi1:49:46

       Mm-hmm.

    5. PAPeter Attia1:49:46

       And it's all my own fault. I've put way too many things on my plate, and so there's no buffer. There's no margin-

    6. SRShireen Rizvi1:49:52

       Mm-hmm

    7. PAPeter Attia1:49:52

       ... for error. One thing, even before this podcast was recorded, I was getting upset about some stupid video I had to record that I was like, "Yeah, but I had to record it twice. It was supposed to be two minutes. The first time I did it, it took two minutes and 20 seconds." Like, uh, like something so dumb that shouldn't even bother me bothered me because I'm out of time. So, so something like external factors will change your distress tolerance window. And, and for me, it's always being too close to the top where it's getting upset. But for some people it's being too close to the bottom, and it's getting, you know, sort of dysthymic or depressive, uh, versus getting irritable. And during good times, like people imagine being on vacation where, you know, for two weeks, like, you don't have to worry about email. Nothing is going on. You know, nothing really seems to bother you. It doesn't... You know, you go to a restaurant and they forgot your reservation. You're like, "Yeah, no problem. We'll go to the next one." Like, it just- You know, I think people can resonate with this idea. So-

    8. SRShireen Rizvi1:50:52

       Mm-hmm

    9. PAPeter Attia1:50:52

       ... one of the skills is how do you make that distress tolerance window higher? How do you make it wider? Um, there's nobody that's not gonna benefit from this. So it's a, it's a long rambling question, but really where I'm going is you get somebody that comes in, where do you start?

    10. SRShireen Rizvi1:51:09

        Well, I will say that one of the, when, when you just said that, what I was reminded of is what is learning what makes us more vulnerable-

    11. PAPeter Attia1:51:18

        Hmm

    12. SRShireen Rizvi1:51:18

        ... to negative emotions or stress or distress, and that is another key skill, um, in DBT is to identify and understand what our vulnerability factors are and then to address, 'cause sometimes we could actually solve our, you know, uh, target or treat our vulnerability factors, and our lives just go much more smoothly. You know, when we sleep, uh, decently, you know, when we remove some things from our list so that we're not so stressed all the time, like that could actually solve a number of problems. But where I start with people-

    13. PAPeter Attia1:51:58

        By the way, that's, I, I wanna-

    14. SRShireen Rizvi1:51:59

        Yeah

    15. PAPeter Attia1:51:59

        ... that's, I'm glad you brought that up because I, I, I f- I should have mentioned, that's actually one of the first things Andy asks me every s- I, and I, I work with Andy once a week, so-

    16. SRShireen Rizvi1:52:09

        Mm

    17. PAPeter Attia1:52:09

        ... it, we, every, you know, I've been working with him for two years now. It's always once a week. Um, but that's one of the first questions he always asks, which is, "Tell me what's going on physically," right? So, "Are you in pain? Are you sleeping? Uh, what are the other vulnerabilities?" And I think out of the gate, he's trying to gauge what state I'm in as a function of how many things are pressing me.

    18. SRShireen Rizvi1:52:35

        Mm-hmm. And what, uh, and, I mean, I can't speak for what Andy's doing, but, uh, and how, um, in those moments, how able are you to receive info? Like, if you're at, you know, a 90 on a scale of 0 to 100, you're not taking in a lot.

    19. PAPeter Attia1:52:54

        Right.

    20. SRShireen Rizvi1:52:54

        You're not learning a lot, right? So we, if you're at that level, then we need to figure out how do we get you regulated enough so that you could learn, uh, learn to do something differently, and I think that that's great that he asks those questions. I think for myself, when I'm in physical pain, I, I just can't do much of anything, and it makes me admire-

    21. PAPeter Attia1:53:18

        Yeah, yeah, and, or sleep deprived-

    22. SRShireen Rizvi1:53:19

        Yeah

    23. PAPeter Attia1:53:19

        ... as you said. I think, I think, uh, he, he's, he's had me pay much more attention to those things. Like-

    24. SRShireen Rizvi1:53:28

        Mm-hmm

    25. PAPeter Attia1:53:28

        ... if you haven't slept well in two nights, you can't, and you shouldn't assume that you're at your best in terms of your ability to receive both information and tolerate things. Um, physical pain is a very interesting one. I agree with you completely. Um, I'm, I'd love for you to share an example of your own life. I have so many of where I've been in pain, and it's made me more irritable. What, what, what have you noticed, and what do you do about it specifically?

    26. SRShireen Rizvi1:53:57

        Well, what I was going to, I just admire people so much who have chronic pain conditions and, and function in their lives because I have been fortunate to not, I mean, I've had pain, um, but to not have a chronic pain condition, uh, because I think, uh, that would be a challenge, um, for me to learn how to navigate that. But I do think that when I'm experiencing pain, and whether it's, you know, a, a transient headache, uh, that I know will pass, or, um, I hurt my back, you know, exercising, and now I feel it, you know, every which way. I, I personally recognize that as a huge vulnerability factor for me because it makes me more irritable, um, in general and makes me much more likely to, to snap at people, um, or to have less patience for things. So for me, what that means is recognizing, kind of similar to what you said, like, okay, this is going on for me right now. I have to accept this is going on for me right now because I can't just will away physical pain as much as I want to and know that this is a vulnerable time for me. So given that it's a vulnerabil- vulnerable time for me, is there a way that I can reduce demands on myself in other ways, or is there a way that I can treat myself kindly in other ways s- to kind of offset the, the pain that I'm experiencing? And sometimes it's, for me, it's also, um, learning to be more explicit and vocal as it relates to kind of this interpersonal effectiveness, uh, 'cause when we experience pain, it's often entirely, um, experienced within our bodies. Other people may not-

    27. PAPeter Attia1:55:53

        Hmm

    28. SRShireen Rizvi1:55:53

        ... uh, even know that this is happening for us, so learning to say out loud, and now granted, it helps as your kids get older, you can say things. When they're younger, you can't say as easily, "Mommy has a headache," so, you know. But they get older, and you could say, um, "I'm really suffering right now from this headache, so I need to have a little bit of space, um, you know, from this conversation or this situation." So learning to recognize this as a vulnerability factor and then figuring out how can I act more skillfully within this context, um, to prevent the lashing out, to prevent the irritability? 'Cause I don't know if this is your experience, Peter, but mine is that whenever I do act out of anger, I almost always regret it and almost always feel worse about myself, um, afterwards. And so it's almost a selfish process. It's, it's to help the other person by saying I'm not gonna get irritable with my kids. It's to protect them, but it's also to help me [chuckles] not feel so bad afterwards, uh, 'cause my kids will recover. I'll recover, but I don't like how it makes me feel.

    29. PAPeter Attia1:57:02

        Yeah, the, the, the cycle of, of anger and shame And isolation is, is a, is a, a pretty frequent, uh... I, I know the path well. [laughs]

    30. SRShireen Rizvi1:57:10

        Yeah. [laughs]
16. 2:01:19 – 2:08:15

    The DBT chain analysis: assessing problem behaviors and identifying vulnerability factors

    1. PAPeter Attia2:01:19

       So going back to kind of the beginning of the interaction with the clinician and the patient, you start with this idea of what are the vulnerabilities. So once you sort of establish that, and I suspect a lot of that is you'll see it quicker than the patient will. Like, a lot of times, people probably don't appreciate what the vulnerabilities are until they're kind of pointed out, which is no, like, these are... Again, it's a form of validation. These are really clear things that are going to make it more challenging for you to be understanding of others, to be understanding of yourself, to regulate your emotion, to control your thoughts, and ultimately to control your behaviors. So once you establish that, I imagine it's somewhat liberating for people. It's, it's kind of a nice first way to have you validate things for them. Is that usually received that way?

    2. SRShireen Rizvi2:02:16

       Uh, so I think for a lot of people, understanding the vulnerability factors and, and determining ways to reduce their vulnerability is really critical. And you asked me, like, what I would typically do with somebody who first came in, and I think that is something... I mean, I'm used to working, uh, only with people who meet criteria for BPD and are un- usually on the more severe end of the continuum. Um, so I don't have a lot of people. I don't have experience with, you know, people that, um, are not as extreme usually. So I think that for a lot of people, learning about vulnerability factors is really important. But I put vulnerability factors in the context of something that we do in DBT called a chain analysis, which is a way of assessing, um Problem behaviors that people have that they want to change as a way of assessing it in order to figure out how to change it, um, going forward. So vulnerability factors is an element of that chain analysis. So say, for example, you know, you were in treatment with me, and one of the things we were working on is, is this target behavior of you, um, [lip smack] uh, exploding in anger at, you know, various, um, points. We would identify what a, a recent occasion in which that happened, and then we would do an assessment of what were all the factors, events, thoughts, behaviors that led up to that behavior, and then what were the consequences of that behavior. That would be the chain, um, that we assess as a way of identifying, okay, well what can we modify in this chain going forward to make it less likely that that problem behavior is going to show up again. And I think what we've been talking about is addressing what happens actually very early on in the chain, that vulnerability factor. And for some people, and in some situations, working on the vulnerability factor changes everything that follows. Um, but there's other events and circumstances where, uh, it's not about the vulnerability factor, or the vulnerability factor is just one element, but something happens in the environment, a prompting event we would call it, perhaps that sets off the chain. And it doesn't matter whether you got sleep or not the night before, because no matter what, that, whenever that prompting event happens, you're going to explode in anger, right? So we want to work on vulnerability factors, but we also want to identify, well, what are some other critical elements along the path towards the problem behavior that we can address and, and, uh, behaviorally manipulate.

    3. PAPeter Attia2:05:05

       Yeah. I mean, it- w- when you state it that way, it's really obvious because, you know, even using myself as an example, which is probably a more extreme example, nothing ever occurs in isolation. Like I've yet-

    4. SRShireen Rizvi2:05:17

       Yeah

    5. PAPeter Attia2:05:17

       ... to come up with one example in my life where I can say, "Yeah, I, I, I flew off the handle, and it was only because of what was happening in that moment." I mean, it's just not the case. It's if I flew off the handle, this is a situation where I would have barely got upset a day ago or a week from now. It was the literally the six things that had happened, and maybe, yeah, may- maybe I didn't have a great sleep. That's not what caused it, of course, but that made me more susceptible. And maybe this other thing happened, and I didn't deal with it. You know, I didn't confront the person who said such a thing that upset me, and I just sort of buried it and went on. And maybe I, you know, read something on social media, and I didn't even acknowledge that that was very upsetting to me. Somebody attacked me, and I sort of ignored it away. And then I find myself in this situation. And, um, I, I liken it to sort of the, the Challenger blowing up. You remember when the space shuttle-

    6. SRShireen Rizvi2:06:12

       Mm-hmm

    7. PAPeter Attia2:06:13

       ... Challenger blew up? This is, you know, God, almost, uh, forty years ago now. Um, it's so interesting, and I'm an engineer by training, so I, I, I really have a keen interest in, in kind of the ins and outs of that, that type of scenario. And what you realize is, like, there was nothing sudden about that horrible tragedy. Nothing about that was remotely sudden and unexpected when you actually peel back the layers of the onion and go through the entire chain analysis for not just the Challenger, but all the previous space shuttles. And you-

    8. SRShireen Rizvi2:06:47

       Mm-hmm

    9. PAPeter Attia2:06:47

       ... realize how inevitable this was. And on that day, this was almost a foregone conclusion. [lip smack] Um, and yet at the surface, it just, you know, again, now imagine watching that as a spectator. Oh my gosh, how could that happen?

    10. SRShireen Rizvi2:07:04

        Well, it, it ties into the, you would get an A on your DBT test because it ties into the dialectical philosophy of everything is caused, right? And everything has multiple causes. Um, and that is very hard to accept sometimes, and it's also very hard to experience, especially in our dominant culture that wants us to believe that there are simple answers, [chuckles] uh, and there's one person to blame or one root cause. That's, that's what the dominant culture is trying to tell us about everything and anything because that's simple. And it's more complex than that, uh, that there's always multiple determinants, um, of anything, and that we could dissect any behavior, any problem, and see the thousands or millions of causes that led up to that behavior.

17. 2:08:15 – 2:11:58

    Why the regulation of emotions can be so challenging

    1. PAPeter Attia2:08:15

       I have one of the pages in front of me that, um, I've, I've copied from my skills book that has so many of my notes in it. Um, and it, it, the... You probably remember the page. It's, um, it's sort of what makes it hard to regulate your emotions. And I've al- this is probably one of the ten, you know, this is a three hundred and fifty page, four hundred page workbook, but this would be, there's probably thirty or forty pages that I have stickies in, and this would be one of the ten most important, and it's just this great reminder. So just for the person listening to this. So what makes it hard to regulate your emotions? Biology. Let's just acknowledge there are biological differences between us. Our brains are different. Um, I won't go into some of the details there, but, but, you know, anybody who has many kids, more than one, will recognize that they are simply different even if they're raised identically. Um, one that we already talked about, lack of skill, right?

    2. SRShireen Rizvi2:09:05

       Mm-hmm.

    3. PAPeter Attia2:09:05

       So lack of skill because skills were not taught, because good skills were pushed away, or because bad skills were reinforced. I think this comes from it, which is reinforcement of emotional behavior, so g- kind of going back to childhood. This one's very interesting, right? Moodiness, right? Your, your mood in the moment will alter your ability to regulate emotion. Um, this one I can relate to a ton, which is emotional overload. So the more pressure you have on you, whether self-imposed or otherwise, the more difficult it is. And then one that I loved, which is emotional myths. So-

    4. SRShireen Rizvi2:09:41

       Mm

    5. PAPeter Attia2:09:41

       ... mistaken beliefs about these things. And I just ma- I have my own notes here. One of them says, "When I can't regulate, it is almost always the case that at least one, and typically three of these are happening."

    6. SRShireen Rizvi2:09:55

       Mm-hmm.

    7. PAPeter Attia2:09:56

       Um, so it's very interesting. You know, again, three of these really peg to childhood, right? The biology, the reinforcement of emotional behavior, plus or minus skill, and the emotional myths.

    8. SRShireen Rizvi2:10:08

       Yes. I definitely think that they, um, lo- a lot of them are longstanding patterns, and some of them are, are current and also contextual. So for example, there might be a person in your life, just one of many, that actually when you, um, uh, display anger, gives in to everything you're asking, right? And that, this could be totally outside of your awareness, but that means that you're more likely to have that anger response with that person in that context, uh, in the future. I had a while, you know, before my husband, a ex-boyfriend at one point who, um, when we would argue, if I started to cry, he would immediately back down. And this was outside of my awareness that this was happening, but I realized over time I found myself crying a lot more than I ever had [laughs] before. Um, and crying is... I'm not saying crying is good or bad, but I just noticed that that was what was happening because in that context with that person, that behavior was, was being reinforced. And I feel like this could happen so subtly, and, um, it's so contextual that how we, and why we're sometimes different with different people, um, is because of that. This is often, at least as it relates to BPD, is, is like pathologized. Oh, if a person, if you're different with different people, there's something wrong with you. You have no core sense of identity or something. But I would say it's actually pretty normal. We're all different with different people, um, because the contexts, you know, often call for that, and it's a- adaptive to be that way.

18. 2:11:58 – 2:16:15

    The importance of mindfulness skills in DBT

    1. PAPeter Attia2:11:58

       So is it essential for everybody who's practicing DBT to also be practicing mindfulness meditation, given the importance of that first step, which is r- recognizing the thought?

    2. SRShireen Rizvi2:12:14

       It is... Uh, well, we might have to disentangle what we mean by mindfulness meditation because I would say mindfulness as a skill is central to everything.

    3. PAPeter Attia2:12:27

       Y- yeah, sorry, let me rephrase the question. Given the importance of mindfulness as a central tenet to this entire practice, is it also suggested that people use a form of meditation that practices that skill? You know, you, you know, typically focusing on something like the breath or an object and, um, you know, bringing their attention back to that every time it wanders as kind of one form.

    4. SRShireen Rizvi2:12:52

       Yeah. We have actually debated this-

    5. PAPeter Attia2:12:54

       Mm

    6. SRShireen Rizvi2:12:55

       ... uh, within DBT. And I remember actually there was a while that Marsha was, when I was a student of hers and therefore seeing her every day, when, uh, she was on this, this kick, for last of, lack of a better word, saying that, uh, we need to get all the therapists to practice seated meditation, uh, like you're describing-

    7. PAPeter Attia2:13:16

       Yeah

    8. SRShireen Rizvi2:13:16

       ... for at least 20 minutes every day. And actually there's a, um, a form of cognitive behavioral therapy, uh, called mindfulness-based stress reduction, MBSR, you may have heard of it-

    9. PAPeter Attia2:13:28

       Mm-hmm

    10. SRShireen Rizvi2:13:28

        ... for depression, um, in which they, they teach people who are in the treatment to work up to that seated meditation. Um, and they also require that therapists who do MBSR also practice it that way. And so Marsha was thinking, "Do I need to require this?" And I remember even way back when, um, arguing against it at the time because I thought, that's, that's not actually practical for everybody always. I think about a working mom who, a, a single mom with three kids, and to say, "You need to find 20 minutes a day to do seated meditation," is, is, um, impractical. Um, there have been many times in my life where that was impractical as well. So, uh, she n- and part of this was to try to figure out, like, how do we define a DBT therapist? How do we know when somebody is doing DBT? Um, so we, uh, she never ended up requiring or saying that therapists have to do this, but what she would say is that therapists who practice DBT have to have a mindfulness practice, but that practice could be anything, um, under the umbrella of mindfulness. So you do yoga, that's, uh, could be your mindfulness practice, or you do min- you know, you do mindful walking, or you do mindful participating in various things. And I would say that that is something when it comes to clients who are in DBT, we want them to strengthen their mindfulness muscle. Absolutely. And if I have clients who are interested in learning to do seated meditation That's amazing, and I would support that entirely. I think for a lot of the clients that we work with at my clinic, that would be too big a jump.

    11. PAPeter Attia2:15:32

        Mm-hmm.

    12. SRShireen Rizvi2:15:33

        Um, and why Marsha doesn't, doesn't say that clients need to do this, uh, because lots... For a lot of people who are in DBT who might be at that more severe end of the continuum, just sitting with themself and their thoughts and their minds without doing anything to change it, for a minute could be excruciating. Um, so we're trying to build that, that tolerance, of course. But the mindfulness skills in DBT are much more concrete and practical and designed to be used in any moment rather than, um, designed to facilitate a more formal practice.

19. 2:16:15 – 2:23:42

    Opposite action: an emotion regulation skill

    1. PAPeter Attia2:16:15

       You know, obviously we can't cover DBT in any comprehensive manner. There's so much. But th- there are a couple things I'd, I'd love to just highlight that I have found very helpful, and I'd love to kind of hear your, you expand on them. Uh, one is opposite action, which is, um, you know, for anybody who's done DBT, uh, you'll grin when you just... Or, or grimace depending on... 'Cause how hard it can be sometimes, right? Um, do you wanna explain-

    2. SRShireen Rizvi2:16:39

       Mm

    3. PAPeter Attia2:16:39

       ... to people what opposite action is and when we use it? I, I think, you know, what's the use case for this?

    4. SRShireen Rizvi2:16:44

       Yeah, I did my dissertation on opposite-

    5. PAPeter Attia2:16:46

       Oh, I didn't know that

    6. SRShireen Rizvi2:16:46

       ... opposite action. I did.

    7. PAPeter Attia2:16:48

       Okay. [laughs]

    8. SRShireen Rizvi2:16:48

       So opposite action is a skill that falls into the emotion regulation module, and it's a skill for changing an emotion that you don't want to have. And it's simple in concept and hard to execute because, uh, simply put, it's engaging in the opposite of what your urges are telling you to do. So we know, and that's why it's called opposite action, so we know that from emotion science, from our own experiences, that our experience of emotions are associated with an urge to act in particular ways. Um, so when we feel sad, we have an urge to retreat, um, w- or withdraw. When we experience anger, we have an urge to lash out. When we experience shame, it's to hide. Uh, fear, it's to, uh, fight or flight. Um, and so what opposite action says is that when your emotion, um, does not fit the facts of the situation or is too intense for the situation and you wanna change it, a way to change it is to act opposite to your urges. So when I'm sad, instead of withdrawing, I activate. When I'm fearful, instead of running away, I approach, kind of like the exposure we were talking about earlier. When I'm experiencing shame, rather than hide, I actually, um, confront or disclose. Um, and, and so on. So it is really hard to do, uh, but you get better at it over time. I will say that, if you practice. I don't know if that's been your experience.

    9. PAPeter Attia2:18:32

       It, it has been, and I... But, but what I wanna, uh, tell you, and I guess you'll appreciate this given your background especially, is, you know, I, I mentioned earlier anger being a profound emotion that I'm very familiar with. The other one is, is, um [lip smack] ... I don't know what the underlying emotion is. I haven't really figured it out yet. Um, I don't think it's sadness, but it produces a phenotype of needing to isolate.

    10. SRShireen Rizvi2:18:59

        Mm-hmm.

    11. PAPeter Attia2:18:59

        So there's a, uh, a, just a desire to completely isolate. So these are two areas where opposite action becomes very helpful, right? So with, you know, one of the really interesting things that if you told me this five years ago, I would have never believed it, but it's remarkable, is the use of cold water-

    12. SRShireen Rizvi2:19:17

        Mm

    13. PAPeter Attia2:19:17

        ... to calm, uh, the nervous system in, in moments of high fight or flight mode.

    14. SRShireen Rizvi2:19:24

        Mm-hmm.

    15. PAPeter Attia2:19:25

        So that's part of the opposite action effect there. I feel angry. I'm gonna go and do something that's really calming, which is take an ice shower or jump in the cold pool. This is nice in the winter here in Austin 'cause we still have pools open, and they're, you know, really cold in the winter. Um, where I have... But that's harder. Those are harder-

    16. SRShireen Rizvi2:19:43

        Mm

    17. PAPeter Attia2:19:43

        ... to do. It's v- as you probably can imagine, when you're v- when you're at 9 out of 10 activation and your desire is to scream or break something, to then walk yourself back from that is harder. Where I have found, um, opposite action to be remarkably helpful, and helpful to the point where it's now the norm, this i- this might be my biggest win so far, is when all I wanna do is isolate, forcing myself to go and play with my kids.

    18. SRShireen Rizvi2:20:16

        Mm-hmm.

    19. PAPeter Attia2:20:17

        And I remember the very first time this happened. It was about a year and a half ago, and for reasons I didn't understand, it was a Sunday morning, and I just didn't want... You know, I wanted to sit in the office and do work and exercise and just do my own thing and be my own thing. And my wife said, "Hey, we're gonna go to Barton Creek and, you know, play on the rocks and throw rocks in the water and stuff." And again, that's the sort of thing I would have said, "Absolutely not. I'm too busy. I just, I'm overwhelmed. I need to just do this thing." And she would have accepted it. Un- she would have been upset, and she would have accepted it, and she would have left. And I was like, "Okay, let's go." Now, I didn't wanna go at all, Shireen. I mean, the thought of not getting my work done-

    20. SRShireen Rizvi2:21:03

        Mm-hmm

    21. PAPeter Attia2:21:03

        ... and missing a workout potentially, and then going to some place where it's totally unstructured, and there's gonna be other kids potentially, and it's gonna be loud, like that, everything about that was unappealing. And we had this amazing time doing nothing, literally playing games, like who could get across the creek without getting the most water in their shoes and, you know, e- exactly what you'd expect.

    22. SRShireen Rizvi2:21:28

        Mm-hmm

    23. PAPeter Attia2:21:29

        And then on the way home, we stopped and got a burger and fries, like the last thing I'd want to do, right? Like we did everything I would never [laughs] want to do.

    24. SRShireen Rizvi2:21:36

        [laughs]

    25. PAPeter Attia2:21:37

        And I got home, and I felt great. And I didn't get as much work done, and, you know, I... And now that's become kind of the realiz- Like you do that enough times that you realize this really works. This is the key-

    26. SRShireen Rizvi2:21:49

        Mm-hmm

    27. PAPeter Attia2:21:49

        ... to, for me, this is important. When I don't want to engage with anybody, go and engage with my family 'cause that's byf- that's the drug to get out of this. So-

    28. SRShireen Rizvi2:21:59

        Mm-hmm

    29. PAPeter Attia2:21:59

        ... yeah, I think opposite action is really a remarkable tool. Even the, y- think of a simpler one, smiling when you're furious.

    30. SRShireen Rizvi2:22:08

        Mm-hmm. And meaning it, right?
20. 2:23:42 – 2:29:13

    Advice for those wanting to explore DBT

    1. PAPeter Attia2:23:42

       So wh- what else do you think it'd be really interesting for a person who's never heard of DBT to kind of understand as they themselves contemplate, "Hey, is this something, is this a new skill I should learn," right? It's, it's no different than saying, "I'd like to learn tennis because I know that as I age, full court basketball might be hard for me, but tennis is something that I'll be able to play for longer. Therefore, I want to go and learn this skill."

    2. SRShireen Rizvi2:24:13

       Mm-hmm.

    3. PAPeter Attia2:24:13

       "I'm gonna need a coach, I'm gonna need to practice, and a year from now I'll be better than I am today." But I mean, is that, do you think that's a, a, a good way to think about DBT?

    4. SRShireen Rizvi2:24:24

       Well, I do with, with some caveats. So you know, anybody who reads any news, uh, or is living their lives right now knows that what we're hearing about is the idea that we're in a mental health crisis or that there's endless mental health crises right now. And what we know is that there are just simply not enough mental health providers to treat all the need that's out there. And what that has meant on a practical level is that there are huge long waiting lists for treatment everywhere, um, for most people. A- and, uh, and I don't think that, we don't want that to deter people from seeking out help when they need it. But the point I want to make as it relates to that is that I don't think everybody needs full on DBT. And, um, and we don't yet have the science really, this is actually an area of, of research that I'm interested in, is trying to figure out who does need the full package of DBT versus who can benefit from a, a lighter touch, a lower dose, you know, whatever word you want to use there. Um, because we want to be efficient in our mental health delivery, and we also want people to learn, um, uh, to reduce suffering of people on a, on a mass level. So-

    5. PAPeter Attia2:25:48

       I, is DBT something... Sorry to interrupt, but just to kind of, this'll fit into what you're saying. Is DBT something that can be done somewhat effectively on your own? Meaning with manuals, with books, with videos online, um, versus the way you would work with, you know, people who are much sicker where y- you have to be working with them directly in person.

    6. SRShireen Rizvi2:26:12

       So this is what we don't know yet. I think we have some assumptions-

    7. PAPeter Attia2:26:15

       Mm-hmm

    8. SRShireen Rizvi2:26:15

       ... about this. Um, but I don't even know if our assumptions are that valid. But I think, uh, you know, the assumption was always, for example, that if somebody is experiencing suicidal thoughts, they absolutely need, you know, some form of treatment, and it needs to be in person, and it needs, you know, to be X, Y, and Z. And I think COVID actually threw us into this new world that we weren't expecting, um, because we had to start treating people who were suicidal virtually, for example.

    9. PAPeter Attia2:26:50

       Wow.

    10. SRShireen Rizvi2:26:50

        And we were able to realize that this idea that we had to see people in person was a myth that we believed. Um, and there were reasons why we believed it. But, uh, but there doesn't seem to be any, uh, as far as we know so far, any added risk of seeing somebody through telehealth when they're suicidal. So I think a lot of our assumptions about what people need are, are assumptions that we don't actually know a lot about. So one of, uh, an area of research that I'm interested in and that I actually applied for some funding to do is to do kind of a stepped care model of DBT to start everybody with what we might call a low dose intervention, like videos of skills, and see what percentage of people benefit from that And from that alone versus what percentage of people don't benefit enough, need something else, and then what can we add to that that would be a slightly step up-

    11. PAPeter Attia2:27:54

        Hmm

    12. SRShireen Rizvi2:27:55

        ... like maybe some phone coaching. You get a call with somebody once a week about how to apply the skills in your daily life. Then, then test it again, right? And then if you're not responding to that, maybe then you get offered the full package of DBT or something else. And we basically can identify through that kind of study what are the sequences of care that are going to be most effective that will help the most people and can be disseminable. So that's, that's an area of research that I would love to do. We don't have a lot of knowledge about that. So I'll, but I'll say, and I think we spoke about this very early on, is that I honestly believe that anybody could benefit from learning DBT skills. And so to that end, I would say, yes, I think there is a value to your listeners to say, expose yourself to some of these skills. See if... And there are videos, there are books, there are things that you could do to learn more about them. Um, see if you resonate with them. See if you can apply them on your own. And if you want to know more or you're struggling to apply it in your life, then that might be where you could reach out for, for help and find a DBT therapist.

21. 2:29:13 – 2:36:04

    Finding a well-trained DBT therapist

    1. PAPeter Attia2:29:14

       Now, speaking of that step, Shireen, how does a person know when they find a DBT therapist? How can they verify that they're, you know, well-trained? I mean, you're probably an exception in that you trained directly with Marsha. Um, there are obviously a number of people who trained directly with her, but, you know, that's not scalable. So at some point-

    2. SRShireen Rizvi2:29:35

       [laughs]

    3. PAPeter Attia2:29:35

       ... you're gonna meet a, a potentially wonderful therapist who doesn't have that, that lineage. So how, how is, um, how, how is the field of DBT self-regulated or self-policed?

    4. SRShireen Rizvi2:29:47

       So it's been a long-standing process [laughs] uh, to try to figure this out. Um, and, you know, mental health is really screwy [laughs] in this way because there are so many ways in which a person can provi- can become a therapist, hang a shingle outside their window and practice therapy. And, um, and that person can call themselves a DBT therapist or a CBT therapist or any kind of therapist and, and may not have the credentials or training to back that up. So I would s- I always tell people to kind of proceed with caution and to do your research when you're looking into finding a mental health provider. Um, so we, Marsha was against this for a long time. She was against this idea of, um, certifying DBT therapists. She, she didn't want to have a regulatory role. She wanted people to learn DBT and to just sort of get DBT out there. Um, but then she was hearing more and more stories, as we all have now, of people saying that they received DBT, and it didn't work. And then you ask them what happened in their treatment, and you hear details about their treatment that were clearly not DBT. And so there's... And, and, you know, the worst case scenario is somebody, um, dies by suicide or, you know, has a terrible outcome, um, thinking that they're getting DBT when they're not.

    5. PAPeter Attia2:31:24

       Hmm.

    6. SRShireen Rizvi2:31:26

       So a few years ago, uh, uh, she started the Linehan Board of Certification, LBC, which has started a certification process for DBT therapists. So what I will say is that, um... What's the logic here that I'm finding the, um, hard time describing it? But so all people that are certified by LBC to be DBT clinicians are likely good clinicians, good DBT clinicians, 'cause they've met all of these standards. But not all people who are not certified- [laughs]

    7. PAPeter Attia2:32:02

       Right

    8. SRShireen Rizvi2:32:02

       ... are bad DBT therapists, right? Because there's a number of DBT therapists who have just elected not to go through the process of certification. So if you're first starting to, to think seriously about DBT, you might start by looking up certified DBT therapists, but recognizing that that's not the only criteria to use.

    9. PAPeter Attia2:32:22

       Are there any other questions that a person can ask to determine if the pedigree of the person who's gonna be conducting their therapy is truly in line with the principles of DBT as opposed to, you know, something that's been bastardized, uh, and, and, and sort of misused?

    10. SRShireen Rizvi2:32:42

        So I'll share another Marsha anecdote in response to that question because, uh, relatively early on, sort of after the initial trials of DBT were put out, um, showing that DBT was effective, insurance companies started getting interested and w- um, wanted to pay for DBT but didn't wanna pay for non-DBT. Um, and so they would call Marsha up, and they would say, "This person says they're doing DBT. How do we know if they're really doing DBT so that we can reimburse for the service?" And she thought about it and ultimately said, "Ask them if they're... ask the DBT provider if they're on a consultation team." Now, I think that this is oversimplified by far, but I'll explain that one of the aspects of DBT, uh, or one of the components of the full package of DBT, in addition to individual therapy and skills training, is that the DBT therapist him or herself attends a weekly consultation team meeting-

    11. PAPeter Attia2:33:46

        Mm-hmm

    12. SRShireen Rizvi2:33:46

        ... with other DBT therapists. And the consultation team meeting is a place where, uh, DBT therapists talk about their experiences delivering DBT with an aim towards improving their own adherence to the model and their motivation. It's often called, um, therapy for the therapist. And, uh, and I think Marsha's response to that question was important because, uh, in many places somebody might say, "I want to learn DBT and I can..." A provider might say, "Oh, I've learned the DBT skills and I can teach my clients DBT skills, and I'll just, you know, pick and choose what I want to do out of DBT." And the first thing they elect to drop is the consultation team meeting because it's time, right? It's time and effort, and it's, and it's centered on you improving yourself as a therapist. So I think it's, I think it holds up though as a reasonable question to know to what extent is the person that you're, that you're looking into adhering to DBT principles is to ask whether they're part of a DBT consultation team.

    13. PAPeter Attia2:34:57

        That's a, that's a great litmus test, actually. I really like that.

    14. SRShireen Rizvi2:35:00

        I don't know how many people... Yeah, I mean, I don't... It'd be interesting to know.

    15. PAPeter Attia2:35:03

        I mean, I- it's funny 'cause I hear Andy talk about his, um-

    16. SRShireen Rizvi2:35:06

        Mm-hmm

    17. PAPeter Attia2:35:06

        ... you know, not surprisingly, but, uh, I never really thought of it as a great litmus test as well. So.

    18. SRShireen Rizvi2:35:11

        Yeah.

    19. PAPeter Attia2:35:12

        Sh- Shireen, this was fantastic, and I, I know we're gonna get to meet in person in about six weeks, so I, I'm really looking forward to that. But, uh-

    20. SRShireen Rizvi2:35:17

        Me too

    21. PAPeter Attia2:35:18

        ... thank you so much for your, for your time, uh, today. And I, I think, you know, this is a hard topic 'cause they're, it's so big, and it's so big to get your arms around it all. And I, I want people to come away from this not at all thinking that they know what DBT is necessarily from this, but I hope we've piqued someone's curiosity such that they go out, they, they watch some videos, they maybe pick up a book or a skills book and decide, "Hey, is there something in here for me?" And, and maybe for some it means going as far as, you know, someone like me has gone and, and saying, "I'm gonna make this a regular part of my training."

    22. SRShireen Rizvi2:35:50

        Yeah. Great. It was really fun talking to you, so thank you.

    23. PAPeter Attia2:35:53

        Thanks, Shireen. [upbeat music]

Episode duration: 2:36:04