176. The Power of DBT: How to Change Your Behaviors & Cultivate Hope feat. Dr. Maddy Ellberger

Jan 19

listen to this episode:

Today's guest is Dr. Maddy Ellberger, PhD, LCSW— a licensed clinical social worker and adjunct professor at Columbia University who received her Masters and Doctoral training in Clinical Social Work from Columbia University and New York University. She is the founder of Downtown Behavioral Wellness, a therapeutic practice that utilizes cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and mindfulness-based stress reduction (MBSR).

In this episode, we discuss:

+ Differences between CBT & DBT

+ The origins of DBT

+ How DBT works to change behaviors

+ What people who thrive in DBT have in common

+ The crucial role of diary cards in DBT

+ Why it's important that parents participate alongside teens in DBT

+ How invalidating environments play a role in mental health

+ What to do if you're feeling hopeless about therapy

+ Mental health advice everyone should know

+ so much more!

Maddy's Instagram: https://www.instagram.com/millennialmindfulnessdoc

Mentioned In The Episode…

+ Downtown Behavioral Wellness

+ Contact Maddy

+ Cognitive-Behavioral Treatment of Borderline Personality Disorder

+ Building a Life Worth Living: A Memoir

SHOP GUEST RECOMMENDATIONS: https://amzn.to/3A69GOC

About She Persisted (formerly Nevertheless, She Persisted)

After a year and a half of intensive treatment for severe depression and anxiety, 18-year-old Sadie recounts her journey by interviewing family members, professionals, and fellow teens to offer self-improvement tips, DBT education, and personal experiences. She Persisted is the reminder that someone else has been there too and your inspiration to live your life worth living.

a note: this is an automated transcription so please ignore any accidental misspellings!

Sadie: Welcome to She Persisted. I'm your host, Sadie Sutton, a 19 year old from the Bay Area studying psychology at the University of Penn. She Persisted is the Teen Mental Health Podcast made for teenagers by a teen. In each episode, I'll bring you authentic, accessible, and relatable conversations about every aspect of mental wellness.

You can expect evidence-based, teen approved resources, coping skills, including lots of D B T insights and education in. Each piece of content you consume, she persisted, Offers you a safe space to feel validated and understood in your struggle, while encouraging you to take ownership of your journey and build your life worth living.

So let's dive in this week on She persisted.

Maddy: the hallmark for anybody who comes into DBT is a combination of feeling like nobody understands them.

Feeling like no treatment will ever work. you come to all these different therapies, , , it's not working. No one really understands how you feel. And you just feel like the way that you feel is inexplicable. Like, there's just nothing you can do.

You are a slave to like,, the ocean of your emotions. That I think is something that really unifies so many people who relate to DBT.

Hello. Hello and welcome back to She Persisted. I am so excited you're here today We have an incredible episode.

I loved having this conversation. This episode is for the DBT nerds But also, if you are new to dialectical behavioral therapy, if you've never heard of it, I highly recommend tuning in because we talk about a lot of things that anyone can implement or that you can just educate yourself on what DBT is and how it works.

So, our guest is Dr. Maddie L. Berger. She is a licensed clinical social worker and adjunct professor at Columbia University, she received her master's in doctoral training in clinical social work from Columbia in NYU. She's also the founder of Downtown Behavioral Wellness, which is a therapeutic practice that uses CBT, DBT, and MBSR.

So this is an incredible conversation when it comes to people that know DBT, Maddie is it. She makes incredible content on social media. If you are like a really big DBT fan and you love seeing how people incorporate that in their daily life or how you can use a DBT lens to understand and incorporate different things, I definitely recommend following her.

But in this episode specifically, we are talking about the differences in CBT and DBT, so cognitive behavioral therapy and dialectical behavioral therapy, because these are two different things, often confused, but super helpful to clarify. We talk about the origins of DBT, how DBT works to change behaviors, we talk about what kind of people DBT really works for and people who thrive in DBT, what those people have in common, which I thought was so fun to hear her perspective on.

We also talk about parents being really involved in the treatment process. We talk about invalidating environments, which is such a key pillar and principle in DBT. We talk about what to do when you're feeling hopeless in therapy, because a lot of people that are starting dialectical behavioral therapy have tried everything.

They don't think it's gonna work, and I definitely fell into that box. So I loved getting Maddie's perspective on that. And lastly, we talked about mental health advice everyone should know and implement into their lives. So, If you want to hear about all things DBT and behavior change, feeling more hopeful, invalidating environments, basically just an incredible conversation about therapy, tune in!

And I really hope you enjoy this as much as I did. And if you do, leave a review, share on social media, you know the drill. And of course, everything we talk about will be linked in the show notes. So with that, let's dive in!

Sadie: Well, thank you so much for joining me today. And she persisted.

I am so incredibly excited to have you on the show today and talk all things dbt. Thank you so much for being here.

Maddy: I'm thrilled to be here. I love the talk all things dbt. So It's a pleasure. Yay!

Sadie: So, for listeners who are not already following you on social media or haven't heard you on other podcasts, can you share a little bit about your background and how you got into the mental health space, working at Columbia, specializing in DBT and CBT, and kind of choosing that sector of the mental health world?

Maddy: Sure. So, , In undergrad, I went in thinking I was, like, going to be an attorney, and, for the record, I still think I'd be a good attorney, and I kind of feel like some of what we do in DVT, like, is kind of similar to some, you know, negotiation, if you will.

Yes. And I thought that I needed to take econ and so I took an econ class and I was like, this is horrible. I'm never doing this again. So I had gotten a five on AP psych and I was like, all right, I'll just take an upper level psych class. And it was just really natural to me. Like it just was like, this makes sense.

There was no question in my mind. And so I went on an undergrad. Then I went on to. Grad school and in grad school, I was really mostly a trauma person, actually. I was not yet a DBT person. I was a trauma person. , and so I was doing evidence based treatments for trauma, TF CBT, PE, DBT PE, and, CPT.

, and then I took a job after I finished grad school at a practice that was a nice practice. It just wasn't the right fit for me. And a friend of mine was like, If you're looking for a job, this, , really big DBT practice in the New York area is hiring. I think you'd be a great fit. And I was like, YOLO, great.

I had, minimal training in DBT because I did more, like, trauma focused and OCD stuff in, in, , grad school. And so I started that job and I was there for six years and I'm like, I like to say that I think that DBT is a self selecting treatment for clinicians. It's definitely not for everybody and the people that it's for, like, it's just you are a DBT person.

So, , I am very through a DBT person even though not everyone I see right now is A dbt patient or like a, you know, a purist, if you will, there's always going to be dbt. My style is very dbt , and so I just really haven't looked back. I Have experienced supervising I was the director of mindfulness based programs and trauma programs at my old dbt practice My practice downtown behavioral wellness is a dbt cbt practice located in new york city And we we actually just hired our first Therapist, Nicole Rothschild.

She's fabulous. , and so that's, that's me in a nutshell. Oh, and I, I teach on and off at Columbia. I love it.

Sadie: Incredible. And I completely relate to what you're saying, where it's like, you either love dbt and you're like, this is the greatest thing to ever exist. This is the Bible or you're like, I don't get it.

And it's so interesting, but I'm really excited for all of the listeners who haven't heard about dbt to kind of get a little bit of an understanding today. You mentioned CBT and DBT, and I feel like one of the most common misconceptions is that they are the same, or that they are interchangeable, or maybe like DBT is a branch of CBT.

So, for listeners who don't understand the difference between the two, what's the difference between cognitive behavioral therapy and dialectical behavioral

Maddy: therapy? So, for the record, Marsha's first book on DBT is called Cognitive Behavioral Therapy for Borderline Personality Disorder. So, there is some truth to the fact that Dialectical Behavioral Therapy is a cognitive behaviorally informed treatment.

The way that we really talk about it is it's a big B, little c treatment. So if c stands for Cognitive Behavioral Therapy, CBT, in DBT we're more behavior forward, in CBT it's more thought forward. Like changing thoughts versus changing behaviors in order to get desired outcomes, reach your goals, have a life worth living, in a nutshell.

Sadie: 100%. And I think that's a very helpful distinction to make. And I think it's something that's also really reassuring when you're going through the process. If you've worked with a CBT therapist before, and they're like, just think differently, like just rewire these thought process is, and then you get to DBT and they're like, okay, we're going to do some deep breathing and you're going to do an ice dive and you're going to feel less anxiety.

And you're like, oh my gosh, there's like a straightforward way to go about this. And again, build that life worth living. So. Can we talk a little bit about the origin of DBT? Obviously, you mentioned her first book, which talked about it as kind of like an adaptation of CBT for Borderline Personality Disorder.

But for people that don't know how it was developed, or why it was developed, or what populations it was created for, can you give a little background there?

Maddy: How deep do you want me to go? Do you want me to go into Marcia's history?

Sadie: I love Marcia's history. Her memoir is like one of my favorite books. So let's

Maddy: do it.

I love it. So, so I will briefly talk. I'm not an expert on Marcia Linehan's history, so I don't want to say the wrong thing. And I will say, of course, I read her memoir. Marcia Linehan, , is a person who kind of like came out of nowhere and published this book in 1993. And I believe it was like 2015 or something like that.

She came out of this treatment. It's been evidence based. Like, all the gold standard research trials and RTC is, it shows the effectiveness of DBT not just for borderline personality disorder, but just emotion dysregulation in general, suicidal and self injurious behavior, substance use, depression, anxiety, PTSD, now we have DBT PE, and eating disorders, so it's really applicable across the board, and what Marsha shared in the New York Times in 2000s of some sort, like within the last 10 to 15 years, is that she actually struggled deeply with, , very serious mental health issues, and was in a hospital for many years, and got out of that hospital and was like, I'm gonna do everything different that wasn't done for me, and like essentially created this treatment that is behavioral control.

With like a combination of Buddhist mindfulness, Marsha is actually a Buddhist mindful guru, I believe, or like she's something important in, in the Buddhist world. She like

Sadie: goes for days on end and sits in silence. When I read about that, I was like, she did what?

Maddy: Yeah. She's crazy. Yeah. Yeah. She like goes to the monasteries and to bed and she's done a lot of that kind of stuff.

So, DBT is part cognitive. There is some cognitive stuff in there, right? Like we have check the facts and Some other stuff and it's a lot of mindfulness and a lot of behavior change. Like I said, so what I like to say is if you change your behavior your emotions and your thoughts will follow and it's the actual easiest thing to change Even though it's really hard to change behavior, but it's much easier to change behavior than it is to like fight with your thoughts It's not that easy.

You just think differently. Yeah. Yeah.

Sadie: So I want to start there with this idea that if we shift our behaviors, we can make these very meaningful changes and then our emotions will become not easier, but less challenging to navigate, less overwhelming. Our thoughts kind of follow suit. When you have an individual that comes to you for therapy and they've never done DBT before, they're very overwhelmed, they want to change these behaviors in their life, whether maybe it's like sleep challenges, maybe it's self harm, maybe suicidal ideation, like all these things that DBT is shown to be effective for.

How do you explain this process of behavior change in DBT for them? I think most of us have been like, well, I want to do something differently, or I'll just will myself into not being depressed or not being anxious. And it doesn't always work like that. So how is the DBT approach

Maddy: different? Yeah, it almost never works like that.

Like you can't. You can't telepath yourself into a different way of experiencing your life. You actually have to. So another thing I'm going to give, give you a, like a bunch of Maddie isms. Right. So things that I've developed over the last 10 years of my career. And so one of the things that I say a lot, which , sounds really obvious is nothing changes if you don't change something, like you need to do something different in order to get a different result.

And so. That's what dbt is based on. It's a super active treatment. Like you're not going to just be chatting. There's always going to be stuff you're working on outside of session. There is a whole other arm skills group besides individual therapy. There's the opportunity to get skills from your therapist in the moment in vivo.

We call that phone coaching. And so it's all about. Doing the things and doing the things over and over again, if you think about opposite action, or you think about problem solving, think about radical acceptance is an over and over again skill, the ABC please skills and emotion regulation, even practicing any distress tolerance skills, even though they're in the moment skills, we have to use them in order to remember that we can use them, and then utilize them with more ease, right, that's how we build a habit that takes 14 to 21 days of pure consistency to change a behavior.

And since we are not AI bots, like nobody is purely consistent. And if you add onto that, like a lot of, you know, big emotions and chaos, because that's sometimes what comes big emotions, you feel like you can't change. And so DBT, one of my supervisors of many, many years ago, explained it to me as like, DBT is.

The roadmap, or DBT's blueprint, right? And then it's up to the person to like, pick the wood, and choose the couch, and all that stuff, right? Like, you have to actually build your house, or , you know, pick your destination, and then drive yourself there. And at the same time, DBT gives you a really, I think, supportive, I think, like, what, what comes to mind for me with DBT is that oftentimes when people get introduced to it, they're like, this, makes sense to me.

Like, eventually someone gets to the point where they're like, Oh, I did this and it made sense. And that's what I mean by supportive. It's such a validating treatment because it doesn't actually ask you to change who you are, which is a person with big emotions or a person who struggles with X, Y, and Z.

It asks you to experience yourself in a different way through changing the way you deal with the way you experience yourself. So it's all like self reinforcing, if you will. I love that

Sadie: so much. I've never heard it distilled like that, where you're changing the way you relate to yourself. But it's so incredibly true, because the emotional sensitivity might not go away.

The way that you immediately think about yourself might not change instantly. But as you start to change how you cope with those emotions, and how you set yourself up for success, and establish a baseline of effective functioning, the way that you experience life is Extraordinarily different. I want to ask you a little bit more about this idea of like who you are, because it's a really interesting population that comes into DBT treatment.

When you, like, I was recorded an episode a couple of days ago and we were talking about radical acceptance and willfulness and dialectics. And I still have my worksheets from 2018 and I was radically accepting that people care about me. And I'm like. What is going on with this person? But it's true. Like a lot of people that come into DVT, there's no self compassion.

There's no belief that they can get better. They don't want to get better. And so what are some of these common, I don't know if markers is the right word, but ways that people feel and think and view the world that kind of has led them to the point of requiring such an intensive level

Maddy: of treatment. I think that Something that unites anybody who feels like DBT makes sense for them.

So I don't want to limit that to borderline personality disorder. Yeah. At this point, unless it's like a research based clinic who, you know, X, Y, and Z, like you don't need to meet criteria for borderline personality disorder. But I think the hallmark for anybody who comes into DBT is a combination of feeling like nobody understands them.

Yes. Right. Feeling like no treatment will ever work. Because oftentimes, and I'm sure you could speak to this if you're a DBT veteran, people will come to DBT, like, after they've done a lot of other stuff, and, or had, , hospital stays, and, or, all the different things. And, DBT is viewed as this, last ditch effort, which is kind of unfortunate.

But, you come to all these different therapies, you don't, like, it's not working. No one really understands how you feel. And you just feel like the way that you feel is inexplicable. It's like, you can't,, control is not the right word, but it's like, there's just nothing you can do.

Like, you are, you are a slave to , the ocean of your emotions. That I think is something that really unifies so many people who relate to DBT. , and the facets of DBT that kind of plug into that are that in DBT therapy is really different and you can speak to this as well. Not just the fact that we do skills, you know, every individual therapy is not learning skills.

Individual therapy is not learning skills at all. But the way that DBT therapists practice. And any of my patients who are listening to this or anybody who's a DBT person will know, like, we practice really different. , we are really different. We practice and replace what we call radical genuinism. So, , we're just really straightforward and real.

It's a relationship. And it's, and it's, like, very, you know, your therapist is, , in it with you, which then holds the expectation that you have to be in it with them. You know, and so it really caters to this, , really strong and yet appropriate and effective relationship between the therapist who then helps the patient understand that it's not that no one understands them, it's that no one knows how to express Thanks.

That they can, that they can understand them. Right. And so it builds validation for yourself. You build validation for other people. You help teach other people how to validate you. You learn to accept when other people can't validate you and you find that validation elsewhere. Right. Well, if you're a person who's been through 800 therapies and you're like, why is nothing working for me?

You come into dbt and it's just different. , I'm going to curse, but like, you can't like fuck around in dbt. It's you cannot do the stuff. Like. Okay. Well, you're not gonna get better. That's what I was saying to my patients. Like, you didn't do your diary card? What do you want me to talk to you about today?

And so , , you're really held to task. And even if you don't want to change at first, if you're even a little bit tiny, but willing to , hear something or try something or whatever it is, , eventually, hopefully that becomes reinforcing to you because you're actually proving yourself wrong.

You're proving yourself wrong by doing things differently. So that's that arm of it. So DBT, ultimately, I had a different supervisor tell me this very, very long time ago. , DBT is a treatment of emotion regulation.

At the end of the day, what brings people to DBT is feeling as though they are not in the driver's seat of their emotional responses. Everything is a reaction, right? And so DBT, and this is skills group and skills training, this is that blueprint, right? The skills training gives you the blueprint to be able to feel the things you're feeling without feeling like they are controlling you.

Your emotions are not an 18 wheeler on the highway. Like you're driving a cute sports car. Like you can do it. You know what I mean? You get which your keys out for something more manageable. And it's not a treatment of emotion deletion. Right? So nobody comes out of dbt, not being a big emotion person.

People come out being a big emotion person. And at the same time, somebody who can identify, validate. And respond to those emotions in a very different way than they ever have before. Yeah,

Sadie: 100%. Yes to everything you just said. , you mentioned diary cards, and I feel like this is one of the most confusing things to people that have not done DBT before.

And, as a DBT lover, I still do my, like, Bullet journal habit tracker. It's funny when I started doing more outpatient DBT, we switched to literally doing my diary cards, my bullet journal, because it was just such a fun way to adapt it and still use the skills and the habits. But also it wasn't the super clinical way of tracking what I was experiencing.

And it was really easy to maintain long term because it was in my planner. It was right in front of me every day, but. When you tell someone that they're tracking every skill they're using and the intensity of their urges and what emotions they're having, they're like, are you kidding me? Like, what is this?

So, can you explain the role that diary cards play and why they're so important

Maddy: in DBT? The whole point of DBT is not to stay in dbt, right? Like the whole point of dbt is to give you the tools and the learning to be able to do the dbt on yourself, right? Which means you need to have a high level of mindfulness of how your internal experience relates to your external experience, aka emotions, thoughts, behaviors, right?

How, how do all of these things Turn into actions right and so the diary card the way I describe it to people is this if you want to change things You need to see what's first getting in your way or what's happening when you can't change the thing in order to actually figure out How to change the thing we need information on which emotions lead to which kind of urges What intensity of them and then what behaviors come from that so that we can start to tackle that right?

We call that a behavior chain analysis, essentially, right? That's when you're looking at, you know, , a behavior that was acted on and you are figuring out where you could have done things differently by tracking your emotions, body sensations, thoughts, and actions. And so the diary card helps you do that day to day so that you actually can, number one, start to see the difference between different emotions.

A lot of people come in not being able to identify what emotion is what, you know, and I've experienced this before as well. Like everything feels like anxiety, but actually a lot of it is shame. Right. And so being able to label that differently and being able to know the difference between a worry thought and a shame thought and which behaviors those leads to and which urges those lead to is really important.

So emotional identification, along with emotional identification, it's also, , Being able to learn to actually experience your emotions at a lower level. So it's not just, you know, when we are people who fit into the dbt framework, if you will, it's often zero, it feels like zero to a hundred. That's, and it's, that's not actually it, right.

There is a biological truth to that. And at the same time, we can teach our brains to actually acknowledge or experience something at a lower level, because obviously if we experience something at a lower level, like we're not at the Chernobyl level of emotions, we don't have to . clean up a nuclear mess, right?

Always want to try to get to something when it's not at, you know, a 10. Yeah. And so that's also really important because you have to rate your emotions. And at first it feels really. Sort of like arbitrary because I think it is kind of arbitrary when you're first getting into this, but it becomes apparent and evident through your increase in mindfulness of what you're experiencing all day, right?

So we need that for emotion identification, we need it for emotion regulation in general, like being able to identify and assess where we are. Urges are really important. This is kind of like the cognitive piece of DBT. Urges are the, I want to do something, how badly do I want to do it? Like the thought that we have when it's like, I want to insert whatever that thing is here, send an impulsive text or binge eat whatever it might be, or, you know, just whatever it is that your targets are, how do you start to notice What's happening internally that's making you want to do that more or less like what do you experience feeling that desire to do that in a really big way versus a smaller way. And so you need to be able to identify an urge in order to be able to choose whether or not you want to engage in a behavior.

And so again, it's identifying the urge to. Want to do something that's mindfulness in and of itself. It just slows you down more to then actually be able to not in the beginning, but like choose to act on an urge or not to act on an urge. So we're tracking actions taken. We're tracking urges and intensity of urges.

And we're attacking emotions and intensity of emotions so that we can start to build. Patterns. We need to understand patterns and also again for the patient be able to have a mindfulness and awareness of what leads to what so that they can start to get ahead of things and not get to the end of the road.

The I. V. cards also have a place to track all the skills you're using, which is, I think is so important, because I, say this to patients all the time, like, you don't want to come into therapy and only talk about, the bad shit, and I think a lot of people come into DDBT who feel really hopeless, like, are just really primed to only notice the bad shit, right?

And so noticing doing a skill and talking about that and having your therapist be like, wow, that's so fucking dope. You did, you did that skill there or helping somebody realize they could check that box off because they did do that skill is also another way to help generalize. So it's really all about like, how does a therapist pass the baton to the patient in order to be able to do all the things on the diary card more naturally.

100%. It also doesn't need procession. , you also don't need to come in being like, I needed an agenda because the agenda is basically set for you, which is kind of nice. Yes.

Sadie: 100%. It's funny when I do my now, habit trackers, I always put using skills on there and I, whatever I talk about, I'm like, it's a freebie.

We have to celebrate ourselves for using skills. We use them every day. We use them all the time. You are using some skills in some capacity. And like you're saying, it's worth celebrating. It's a huge win. If you're choosing to. Pull from that skill set and be more effective in

these

Maddy: moments. Absolutely.

Yeah. And I like to say to people, like you're using dbt in the wild before it becomes intentional and you're learning skills. Anything you do that skillful is still skillful, even if you didn't realize it was skillful. So now we just have to bring more awareness to that thing.

Sadie: 100%. It's already there.

Yes, exactly. I want to talk about another thing that people find to be, not odd, but it's definitely unique in DBT, which is the adolescent adaptation, where if you are doing DBT as a teen, your parents are also doing DBT. And if you went into talk therapy and you were like, yeah, parents, you also are equal participants in this.

Most people What are you talking about? But for dbt, it's like, just understood that the family is involved in the family is learning the skills. The family is coming to sessions and doing the work as well. Can you explain kind of that philosophy, why it's so important? And then the benefits of having parents and teens work alongside each other

Maddy: in dbt.

Sure. So this is all from my perspective and my training. I'm like, you know, I'm not voting for a book. I'm quoting for my own anecdotal experience. And so I can tell you a couple of reasons why I believe that. And research shows that having or both parents in group is so important is number one, you can't create change in the home if only one person is exposed to the change, right?

So, and especially a kid, like a teenager can only do so much and if a parent or parents or sibling, whatever, whoever it might be is not understanding, also how to engage in that effectiveness or skillfulness or how to support the other individual who's really learning the DBT, you're just not going to get that far.

Like, I always say to people I'm not coming home with you. You know, you can call me, but I'm not in your house. So I I can't call scene and be like, Hey everyone, do this now. Right. And so having parents in skills group, which is where we learn the dbt skills, six months to a year. I usually have my people do it for a year because I think six months is just too short.

Like I did it

Sadie: for six weeks at some point. And it's like, no, you would need the intensive amount of time to be able to truly internalize

Maddy: all of that. Yeah, otherwise, , how are you, like, you take six months to learn it and then another six months to figure out how to use it. Yeah. , so parents have to be there so that everyone's speaking the same language.

So the parents are also learning how to regulate their emotions, right? So much of what happens, I think, it doesn't matter how old we are, we can be ten or we can be forty five. , and so much of our own dysregulation, like, our own emotional struggles come from interactions with other people. Yeah. Right?

And Obviously, , it's very, a classic trope that, adolescents and parents have a hard time relating to one another and then that sometimes is the perfect storm, right? That sometimes is the unintentionally invalidating environment where parents just don't know how to help, so they just try to make things go away.

And the kid is more emotionally intense, has that biological predisposition, because probably the parents also do, you know, and is experiencing their emotions in a way of like, well, nobody's telling me I can feel this way. And so it becomes this perfect storm of these more intense, dangerous behaviors.

And so parents need to also know when they're stepping into their own traps, parents need to be able to regulate themselves because they can't co regulate. You can't co regulate anybody if you're like, Like I said, Chernobyl, right? If you are a nuclear reactor, , it's not happening. Everyone's a human being, right?

And I think that the third really, , valuable piece of adolescent and family DBT is that it really depathologizes the patient, right? Totally. A lot of folks come into DBT and whether it's coming in as an adolescent and doing adolescent and family DBT by , which was adapted by Jill Rathus and Alec Miller, just to shout them out.

, or if you're an adult and you're doing the, you know, regular adult DBT by, , our friends Marshall Inahan. , you come into DBT, with a lot of people telling you there's something wrong. And this, this really like heavy feeling of there's just something inherently wrong with you because the the things that you experience and the way that you experience them don't look like other people's stuff, right?

You've had therapists be like, this isn't working for you. You need to go. You've had invalidation and acute hospital stays, you know, like there's there's all this stuff. stuff that just, you know, you come in being like what we call in therapy, the identified patient.

And the idea here in dbt, because it is a behaviorally based treatment is that it's not really just one person, right? Like the environment also needs to be amenable to change in order to support someone's change. And so having this co responsibility for. Making these changes in the home. I just think it's very validating for the teen and I think eventually for the parent, I think it also helps the team build empathy for the parent when they're listening to a parent, like talk about something that happens at work or like with a friend that has nothing to do with the kid that led them to, you know, want to send an impulsive text or to slam their door to send an email.

They may be Could have sent differently. Like that is all validating. So it, it just, like I said, deep pathologizes the teen as the only problem.

Sadie: Yeah. You mentioned invalidating environments in there, and this is something in dbt that changed my life. And I was like, this is what I'm feeling. It's something that you don't come across in like health class or in your normal relationships, unless you've been in a lot of therapy, you've probably never heard that term.

You don't understand it. Can you explain that to listeners? Because I feel like it's so applicable to most people that are like DBT works. They're like, I have felt invalidated for so

Maddy: long. Yes, so we talked so Marshall and Ihan created this theory, which has again since been highly substantiated through like neurobiological testing and a lot of other psychiatric gold standard research, and it's the biosocial theory, which is there's a biological basis.

to the experience of borderline personality disorder or extreme emotion dysregulation and there is an environmental piece, right? Okay, that's not brain surgery, like everyone says there's nature and there's nurture, right? So the thing about the nurture in DBT, and I, I personally have a way that I talk about this, so I'm curious to know if this is how you also learned it when you were, Three East.

, but the way that I like to talk about the invalidating environment is that people don't know how to handle other people's discomfort. It's really hard for other people to sit in a boat with someone else and watch them be sad or watch them be angry or watch them feel anxious. And so what people want to do, people around us who care about us, whether they be parents, friends, partners, boyfriends, girlfriends, teachers.

coaches, like somebody will basically do anything that they can do to try to make you not feel that emotion because essentially they're associating that emotion with you not being able to do whatever thing want or need to do. And the message that sends to the person who's experiencing the big emotion is, well, everyone around me is saying, like, this doesn't make sense.

Right? So it might be reassurance, like, Oh, don't worry, it's going to be fine. Right? So it's just like, it's going to be fine. Everything's going to be okay. Reassurance is not validating. It's basically being like, why do you care so much? It's going to be fine over it. Yeah. Like problem solving for someone else.

So being like, I'm just gonna I'll look I'll do the X, Y, and Z. You don't have to worry about it anymore. That completely takes away someone's capacity to number one, be able to figure out anything on their own. And number two, , be able to have an emotion, right? It's just like, I need to take this away immediately.

, people, you know, minimize The difficulty in changing an emotion like, oh, you just have to do this, this, and this, and then you'll feel fine, right? And all of this, I like to say, the people that care about us the most tend to unintentionally be the most invalidating because they just don't know how to help.

And the idea that help equals, , not having the emotion. When oftentimes. We need to be able to know we're having the emotion and experience the emotion in order to choose what we want to do with it next. And so the invalidating environment is one that unintentionally sends us the message that the way that we're feeling something or what we're feeling in general just doesn't make sense.

And eventually, what happens there is that message gets internalized by the individual. So the individual is like, well, If someone's constantly shutting down this emotion, even in a very nice loving way, there must be something wrong here. And so I also can't trust my own responses to situations because they must be wrong.

Because everyone's kind of like always trying to take this shit away from me. So it turns into self invalidation. And then you have other people invalidating you and you have yourself invalidating you. So how are you supposed to be able to do anything? Other than like the first thing that comes to your body that is just going to take that emotion away because that's the message you've received over and over.

Sadie: I, yes, just 100 percent and I feel like it is such a universal experience and I feel like the external and validation is challenging, but that perfect storm of the chronic internal validation, and the external validation that's where you're like, I just. Don't know how to move forward. And those emotions do become so challenging to experience and navigate and all of that, and kind of like the other side of that coin, whenever I talk about dbt and how helpful it is and how much it changed my life.

And it's all, I always give the caveat, like I did dbt four times before I truly saw a shift in my emotions and behaviors and all of that. So it wasn't like I tried it one time and it worked. It, it took many times of being in the right environment and having the right therapist and all of that. But there's so much hopelessness that a lot of people experience when they're starting dbt or when they've tried it and it hasn't worked.

And so I'm wondering what your insight or advice is for people who have tried dbt or they want to try dbt and they are really stuck in that camp of it's not working, things aren't changing. I feel worse and you get back in that headspace of no therapy works for me. I'm just meant to be this way, et cetera.

Maddy: Yeah, and I think that even if you come in DBT waving the DBT flag, you're going to feel that way at some point because behavior is hard, like it's actually really, really hard to do. I always say to people, I hope this is the hardest thing you have to do in your life and like the worst you ever feel because it can only happen here, you know, like it really can.

It's a couple of different things. I think, first of all, there needs to be validation of, like, if somebody's still feeling stuck, then, , yes, it doesn't feel like anything's changed for them. Or, like, if somebody has an idea of what they should be feeling like, right, if they have an expectation that's based on a judgment, and their experience doesn't meet that expectation, it's not actually mindful of the reality, , you're gonna feel like shit.

And you're going to feel like your therapy isn't working even though it's supposed to work, right? And so really being able to I think, have a really genuine heart to heart with your therapist or your therapist having a heart to heart with you being like, well, what's the deal here? Because you come in every week and you say it's not working, but like, I, maybe I don't understand what working means for you.

Right. And so actually having a conversation about what's getting in the way, what's not working, being able to express to someone that maybe the therapist is making some mistakes or doing some things that aren't actually as helpful as a therapist thought they could be. Right. That's really important.

Feedback is so important in dbt. , I always say to people like. Don't walk out of my office and never come back again. I'd so much rather you call me and say here's, here's what I didn't like, like send me an email, we can fix that. Like that's, that means we can problem solve it. But it's essentially this idea of.

Let's get to understand what you're, what you're feeling, what you're not feeling, what you think you should be feeling, who told you to feel that way. And then let's try to sit, let's make a plan. Let's negotiate this. Like I'm not going to, I always say to people, I'm never going to keep you in a treatment that's not working.

And if it doesn't work for you, that doesn't mean that there's something wrong with you. It means that this is not the right treatment for you. Okay. that's not the case because I'm sure you've bounced around a lot and I'm never going to keep you in a treatment. That's not working. Let's see.

If we make X, Y, and Z change based on the feedback, right? If we kind of implement these different things, can we see if we get to this marker by this month? Right? Let's actually keep track of it. It's up to somebody also to be able to really take ownership over noticing what might be different. And so it's a combination of really validating , yeah, like this obviously isn't working for you if you're still, you know, experiencing these higher urges or you're still experiencing high emotions.

What can both of us do differently? And then let's set a marker to be able to , see if it's working or not. Right? I don't want to keep anybody in a treatment that's not going to work for them. That's just not fair. And it's boring and doesn't work for me. I like, I don't like that. So can you be willing, right?

This is where willingness is really important. Can you be willing to put aside or try to mindfully push away this, this is never going to work thought, because by the way, probably won't. If that's how you're thinking and actually just do the stuff differently, forget the thoughts, right? Like forget the thoughts, but can we try to do things?

Differently based on this conversation. So we can actually see if we can get you somewhere else. Yeah.

Sadie: I love that so much. And it speaks to so many different points of my experience with DBT where I first started and I was like, this is working. , they explained a life worth living to me and we were going to work on all these things.

And this was going to, again, be the hardest thing I'd ever done, but it was going to be so worth it. And I was learning the skills, but I was like, emotionally urges behavior wise, just as bad. And if you're working with like a true DBT therapist there. consulting with other therapists, and if things aren't working, they know.

They're like, all right, something is not going the way it should because the urges aren't adjusting, behaviors are the same, there's all this conflict, whatever the problems are. And then after that, we didn't see shifts there, and they were like, we can't do outpatient, we need another level. Then I was like, okay, DBT doesn't work.

It's not gonna work for me, it's not a good fit. And then in residential, they're like, that's not really how this works. works, but we love that you think that, but we're going to have to shift that mindset if you want to stay here. , but what you're talking about, I think is so important with the internal work problem solving, , and also trying to let go of those thoughts and just dive into the actual behavioral part of it.

And

Maddy: it doesn't mean you need to like, when we say let go of those thoughts, it's not like. You shouldn't think it's more like, how do we not engage in them? And I say to people a lot of times, a thought is a behavior. Like when we get engaged in a thought or we think a judgment, that's a behavior.

That's actually something we could do differently. And so when somebody talks about, like, I have a big schtick about. being overwhelmed, or the word can't. Like, I have my own things about, these certain words, and I'm like, if you keep saying that you're overwhelmed, your, your brain is gonna, , freak out.

Of course you're not gonna be able to do anything differently. Can you actually describe what's going on for you? Can you explain what overwhelmed means so that we can start to, to attack each of those things? You have to be, the way you think, is the way you act. And you can actually think of thinking as a behavior.

When you are missing judgments, when you are getting stuck on a thought, when you're practicing over attachment to an outcome, right? We can actually behaviorally change those thoughts so that they are no longer part of our purview.

Sadie: The last thing that I wanted to touch on is you mentioned the goal is to graduate dbt.

The goal is to not be in dbt forever. And the goal is to kind of do these things yourself independently in the wild without realizing that you're actually still using all these skills and being intentional. Are there some different, I don't know whether it's philosophies or behaviors or habits? That you think would be helpful for almost everyone to have in place to keep themselves on a good trajectory.

It's like the expanded police skills of like, we have these core things we need to do, but maybe it's self validation, maybe it's something related to relationships. What do you wish that people had in their toolbox and continuously did to maintain their progress? , or just set themselves up for

Maddy: success?

So. I, , my mentor is a big mindfulness person. She's a mindfulness based stress reduction person. So I, I've done a lot of mindfulness work outside of just dbt mindfulness. And like, my belief is really that everything we do is couched in focused awareness. That's mindfulness, right? And we need to be able to have the capacity to return to this idea that we know what's happening to us.

And we actually have a choice in order to do something differently. Like no skill exists. Without mindfulness. And so I think like, Probably it's an annoying. The answer for everyone. Like the, the actual answer is continuing to pause and asking yourself what's happened to me right now, what, what's going on.

What am I experiencing? What am I missing? What am I judging? Right. And being really aware of. Sometimes making the choice to be an emotion mind. Like you can still be mindful to make it an emotion, mind choice. So it's mindfulness and it's honestly being able to describe as opposed to be judgmental.

I'm a little bit, I'm different than like, you know, other, I think I'm like a little more of a hippie, but no, there's a, there's a bunch of us like this. And so I think that just again, Always remembering that if you know how you're feeling, you can do something about it. , I think that to me is.

The most valuable thing and you don't need any props for that. You know, like we have different distress tolerance skills to do different things. Like we don't need any props to remind ourselves that we actually have choices. Right. That's really important. And I also think continuing to strengthen problem solving, like the way we do it in dbt, , love a dbt problem solve moment.

And, . I think your ABCs are also really important. So you're accumulating the short term and long term building mastery. So like having a goal and understanding how to get there and coping ahead, knowing what doesn't work for you, knowing what might happen in difficult situations and being able to know how you're going to get through that.

But again, all of that really starts with mindfulness. You can't do any of those things without knowing that you need to do those things. Yes. Well,

Sadie: if people want to continue to follow you on social media, they're in the New York area and want to check out their practice. Where can everyone find you?

Maddy: So on social media, I am a millennial mindfulness doc because, and it's like a cheesy name, cause I am very, , and on my Instagram, you can see it's linked to my private practice, which is downtown behavioral wellness.

com. Where, , we are accepting referrals. Like I said, Nicole is amazing. She's going to be getting started and she's. It's hitting the ground running. So we do have spots right now. We have spots in dbt groups. , And that's that all my email contact stuff is, is on my website. So yeah. And feel free to DM.

I'll get to it eventually. Sometimes I'm not as effective as I'd like to be about DOs, but certainly shoot me a DM I'll get there eventually. Amazing.

Sadie: Well, this was absolutely incredible. This was so much fun and thank you so much for coming on.

Maddy: Of course. It was a pleasure.

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