Episode 1: The Power of Dialectical Behavior Therapy

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Katy Tarella always wanted to be a therapist, but when she discovered Dialectical Behavior Therapy, she gained a new passion for the field. As clinical director of outpatient programs at Clearview Treatment Programs, Katy has seen firsthand how DBT can not only help people in their struggles with mental illness or addiction, but also help them build a life worth living. In this episode, Katy explains the philosophy behind DBT and how it’s used in Clearview’s outpatient programs.

Katy: It’s a balance. It’s a mindset and a balance of change and acceptance, focusing on reality as it is. We call it radical acceptance in DBT. And so, while DBT can really focus on, “Let’s get you on track, but then let’s also look at how we might be getting in our way by non-acceptance.” And it’s hard, that parts hard. But that part really, I think, is what brings it all together. [music]

Host: That’s Katy Tarella, Clinical Director of outpatient programs at Clearview Treatment Programs, explaining why she is so passionate about using dialectical behavioral therapy to treat mental illness and addiction. My name’s Clark, and I’m your host of Conversations at Clearview, a new podcast where we’re covering topics like the value of outpatient treatment, therapeutic treatments like DBT, and more. Clearview Treatment Programs is the home of one of the longest-standing outpatient programs in Southern California. They offer individualized outpatient, intensive outpatient, and DBT, day treatment programs, for addiction, mental health, and dual diagnosis. Clearview Treatment Programs is home of one to the longest-standing outpatient programs in Southern California. They offer individualized outpatient, intensive outpatient, and DBT, day treatment programs for addiction, mental health, and dual diagnosis. Clearview is also part of the larger Odyssey Behavioral Health Network, which includes 20 locations that are committed to helping individuals reach their optimal levels of health. In this episode, Katy explains how Clearview’s treatment methods help patients learn the skills they need to build a life worth living. She also provides an overview of what it’s like to participate in one of Clearview’s DBT programs. To learn more about some of the Clearview Treatment Programs and Odyssey Behavioral Healthcare, visit odysseybehavioralhealth.com. Now, let’s get started. [music]

Katy: Hello, I’m Katy Tarella, I’m the clinical director of Clearview’s Outpatient program at Clearview Treatment Programs.

Host: Thank you so much for taking the time. I know how busy you are, and there’s a lot going on always, I’m sure, so thank you for spending some time. I’ve got some specific questions I want to ask you and just want to learn more about your role and the kind of work that you’re doing right now. And I would love to hear throughout this conversation just– I know you have deep connection to this kind of work, and it carries a great importance to you and the lifetime commitment you’ve done with this. So, I would like to first start briefly of just, in a snapshot here, just your background, and then I want to dive into DBT and what that is and how it connects to the outpatient programming. But first, can you just tell me a little bit about yourself with kind of work and study you’ve been doing over the years on all of this?

Katy: Sure. So, I am actually from Massachusetts, a little bit outside of Boston, and I went to grad school at Simmons College for Social Work in Boston. And I worked at McLean Hospital, which is a very renowned psychiatric hospital right outside of Boston and started working as a counselor in a residential program that specifically treated women with borderline personality disorder. And that is where I fell in love with DBT, or dialectical behavior therapy, because that was the main treatment modality that we used and what I was extensively trained in. And then kind of focused my grad school and after on becoming more of a DBT expert, training others, treating clients with this amazing treatment that can do so much and touch so many people. And so, I was at McLean for about 10 years, and then made a big move across the country to San Francisco a few years ago. And now I’m in L.A. and excited because in my experience so far in this field, Clearview has been a place that I’ve known about from the early kind of working at McLean Hospital and going to school. And as kind of life goes, I ended up working here and I’m thrilled. This is somewhere I’ve known about for a long time and has such a wonderful reputation.

Host: That’s wonderful. And I’m really curious to ask specifically about DBT. And you were saying– out of all the work you’re doing, you use [inaudible] you really fell in love with this. And so, can you tell me more about what you mean by that? And so, it’s a treatment, right? So why did you feel that way and why do you think it’s DBT specifically? What makes that really stand out to you?

Katy: Sure. Yeah, I think it’s an interesting wording I used, but I mean it’s because I always wanted to be a therapist for a long time. Went to grad school and it became more attainable to me. And as I was learning DBT, I just felt this kind of opening to a world of exciting treatment. It really opened a whole new chapter of, “How can I both integrate this into my own life?” actually. I think that that’s a common experience for therapists or clinicians who are getting trained in DBT, is this aha moment of, “Wait a second, this is very applicable, this is about using skills to make my life more what I want it to be and to deal with relationships and tough emotions in a way that’s really attainable.” So, I kind of take it from there and see, well, I’m working with the clients, and maybe I’ve been using CBT, cognitive behavioral therapy, which is a very, very effective treatment. And then there’s DBT, which folds in a layer of acceptance and mindfulness-based treatment and kind of uses this idea of dialectics as the idea that two opposing ideas, two things that seem like they can’t ever find a middle ground, that’s actually not true. That in DBT we focus on this foundation of a dialectic between acceptance and change, and so they go hand in hand. And I think prior to learning about DBT and getting immersed in that treatment, it seemed to me like it had to go one way or the other. Either you need to focus on changing your behaviors to make your life more sustainable and to get some relief, or you go more of the mindfulness and acceptance and kind of supportive therapy route. Both are valid, it’s just that DBT brought in this integration that felt really exciting, I’ll use that word again. It felt exciting and rejuvenating and sort of like I could really see myself using this in a wide variety of contexts with different clients — kind of across the board. 

Host: Yeah. That’s so interesting. And you were also, if I heard you right, you were saying it’s something that even you said you could like, “Hey, this is not only something great for my patients, but this is something I can be doing too.” Is that right?

Katy: 1,000 percent.

Host: Really? Okay, that’s– what do you think makes it that way? Can you maybe give me a quick crash course — you mentioned mindfulness, acceptance, and change? I want to learn a little bit more about DBT, and then we’ll talk a little bit about how you’re able to use it as a vehicle for outpatient programming.

Katy: Sure. Okay, crash course. So DBT, dialectical behavior therapy, is a treatment modality that is evidence-based for the treatment of emotion dysregulation problems

Host: Emotion dysregulation problems.

Katy: Yes. So, what that means is having difficulty– for a variety of reasons, having difficulty with emotions that feel too intense to manage, that come on too quickly, you don’t see them coming, and make you feel like you need to react to a situation immediately to try to alleviate the intensity of your emotion.

Host: And this can be I guess anything, right? I mean, that can be family-connected, it can be just regular life-connected, maybe work-related.

Katy: Absolutely. That’s why it does really help across the board. And what I will say is that DBT was created as a treatment and years and years of research to validate its efficacy, that DBT was originally created to help treat folks who were dealing with suicidal ideation, so that means thinking about suicide. And not necessarily doing things that are suicidal, but rather this experience that Marsha Linehan, who created DBT, was seeing in her clinical work that lots of people were coming back to treatment over and over because they weren’t getting the help they needed to deal with this suicidal thinking and self-harming behaviors. So those are two things that DBT originally targeted and tried to address in a different way than any treatment modality had before. It was pretty groundbreaking.

Host: So, in the past, they were receiving almost– not a Band-Aid, but they were getting very specific help in a very specific way, but then when they would leave, maybe that wore off, in a way. But now, if I’m understanding it right, DBT is more of a– this is a new set of skills that anybody can use, and B, it’s especially going to be helpful for some of these problems that these other methods weren’t addressing long term.

Katy: Exactly. Yep, that’s exactly right.

Host: Okay. So, anything else you want to touch onto, or just kind of what makes this specifically different, what makes it special? And then we can kind of start talking about how you use this set of skills and help provide this to the patients you get to work with.

Katy: Sure. I think if I could add anything else to it, it would be that DBT– and we can talk more about this maybe not in this moment, DBT is pretty kind of layered in what it offers to anyone coming to use it. So right away you can get skills to cope with emotions right away, dive right into that, and that’s what we’re good at doing here at Clearview in our outpatient program. And it also kind of helps you build that muscle of mindfulness, which is essential to this treatment, which is becoming more aware of your present moment and less judgmental and less needing to kind of distract oneself a lot. All of us can relate to this. If you’re anxious or angry, how difficult is it to not sit with it, think about it, ruminate about it, and be really upset for a long time and not get relief? These skills are like, “Nope, let’s help you intervene early, right away, get you some relief from the pain and the suffering you’re having with these emotions, and also help build a life worth living.” Which is really the kind of motto of DBT, is build a life worth living. Use these skills and this treatment to make a life that feels meaningful and purposeful to you so that you can keep at it, you can– it’s a bigger picture. Which is so amazing. I love that about DBT.

Host: That is great, build a life worth living. Okay. So, we’re going to talk now– I would love to hear how this looks played out in real life, right, with working with your patients, and when are you basically able to teach? Is this a taught thing? How does that part work?

Katy: Yeah, yeah. What does it look like when you actually say, “Okay, I’m going to do DBT treatment,” what does that look like?

Host: Yes, that’s what I was [crosstalk] [laughter]. That’s exactly right.

Katy: Sure. So, it is a kind of didactic classroom-based treatment. So, it’s kind of twofold. So, when someone comes into and agrees to, there’s lots of commitment building. And the therapist and the client– the thing about DBT is we’re in it together, we are in this treatment together, this is not– this is your treatment, the client takes ownership of it, but I’m in. That’s what I try to say to my clients, “I’m in 100%. Can you meet me there?”

Host: With them.

Katy: Yes, “With you.”

Host: Okay. So, you’re really going through this– you’re not at the end of the tunnel saying, “Hey, I need you to take one step after another, but–

Katy: No, we’re going to do this together.”

Katy: We’re going to go through this together, we’re going to go through the thick of it, and you’re going to see that you can experience all of these emotions and situations that feel like you can’t get through them, and we’re going to do it together and you’re going to see that you can get through them.” But what I will say is when– yeah, when you start DBT, you work with a therapist individually, who’s your individual therapist, but the other part of DBT that’s very substantial is the groups. So, you go to a DBT skills group and you’re kind of thrown into this classroom, teaching type of group. And it’s all about teach a skill, talk about it, kind of troubleshoot, and then you’re given homework and you go and practice this in real life. And you come back to group the next week, you talk about how it went, troubleshoot again, learn a new skill. It’s very structured. And then you have your individual therapist to take what you’re learning in groups and come back and say, “Here’s what I’m actually experiencing, this came up, this is something I can use this skill with.” And you get to integrate the two so that you’re not needing to use your individual therapy to be taught the skills. It’s like they really complement each other.

Host: Right. And so, when you say the start, you kind of get thrown into the room, is everyone starting this at the same point, or is it sort of a rotating situation? Did that make sense?

Katy: Yeah, that’s a great question. It’s a rotating basis. Not always, but I’ll say the way our outpatient program works is that we have an ongoing DBT skills group that meets three times per week, instead of one time per week, and the clients are getting comprehensive and intensive deep dive into DBT and learning how to use it. So, you may end up coming into a group when they’re working on this skill, and you kind of must– we always tell clients starting out like, “Hey, know it’s going to be a little confusing at first.” You’re kind of jumping in–

Host: It’s a lot. Sure. And there’s people already kind of doing that, right?

Katy: Yes. “But hang tight. We know for like two– so say give it two weeks, you’re going to see that kind of click coming– give it some time, you will kind of fold into it.” But yeah, that is part of– that’s part of the way the treatment works, is you kind of jump in.

Host: Okay. And so, the advantage of that is some people who’ve already– they’re already in the weekly meetings, I want to imagine that they can sort of lend a hand to some of the newer folks, and you kind of get that cycle maybe.

Katy: Yeah, that’s right.

Host: And then the new person becomes the person who’s been around and can kind of help.

Katy: No, you’re right, actually. That’s a thing that naturally happens. It’s a very– DBT is a really kind of community-based group support, non-stigmatizing, nonjudgmental place where people do connect in a way that’s different, right? They hold each other accountable, they support each other, they kind of talk about, “How did you use this skill? What did you do for your homework? This didn’t work for me.” And that’s the ideal kind of flow of a good DBT treatment, which is something I think we’re really, really skilled at here at Clearview. Our clinical team is amazing. They are a fantastic group of therapists who are really dedicated, I think, to do the type of treatment we do in an intensive outpatient setting using DBT. It’s a lot. It’s stressful, it can be intense. And that’s why we work as a team. And we support each other, and we meet several times a week to talk about what’s going on, what’s going on with this client or that client. And all our clients know that we work as a team. And that’s how DBT works too, that’s the other part of it that I really love, is that you’re not working alone. It’s essential to DBT treatment that you meet as a team in what we call a DBT consultation team, and we talk about how we’re doing, how we’re managing and taking care of ourselves. Because we must practice what we preach. We hold each other accountable on the foundations of DBT, like if somebody’s saying something judgmental, we ring our [inaudible] bell and just notice. It’s what we would have our clients do, and so we really try to embody it. And there’s a lot of community building that comes along with that, both for clients and the clinicians.

Host: It’s totally clear how much you love this and enjoy this work. I mean, I know it’s hard work from what I’ve been reading about it and as I learn more about it, but it’s important work. And next, I want to ask you a bit about– you used this phrase earlier, “Nonjudgmental.” And I was curious about how that plays role with families. And when a community is supporting someone, a family or anyone like that, and they know a loved one is getting support and getting this new set of skills, I’m curious if there are any myths that are related to that or, I don’t know, misunderstandings or anything like that. What has surprised you over the years about myths with DBT?

Katy: Good question. So, I think that– just off the cuff, I know I hear a lot “DBT doesn’t work for me, I’ve done it before.” Or “DBT is all surface, it’s all about let me just learn some skills, but what about the stuff underneath?” So, what I’ve learned over the years is that DBT becomes a mindset that one can have, and a skill set that you can come back to. And that the idea of, “I’ve done DBT before,” while I do appreciate that and understand what most people mean when they say that I think it comes out of feeling frustration that they haven’t made progress that they would hope, or they’re still struggling with difficult emotions, difficulty in relationships. And for myself, the first time I learned how to use distress tolerance, is one of the modules in DBT, I practiced those skills on my own to learn them. And when I used them let’s say five years ago, it’s much different than how I would utilize them now. That is an important piece. Because when people come into our outpatient program at Clearview and they’re doing our comprehensive DBT treatment, it’s kind of your first touchpoint. And maybe it’s your third or fourth touchpoint with DBT. But what helps a lot is taking that nonjudgmental stance and kind of buying into the idea that this will be a treatment and a set of skills and a mindset that will stay with you. And it’s helpful to think about different phases of our lives, right? So, one might be just having graduated college, going to grad school, maybe going through some difficult times in a relationship. Our lives are ever evolving, and so I think the idea here I’m trying to convey is that when you have really given DBT and the skillset and the mindset of dialectics a chance, you can come back to it. And it’s always going to be a helpful toolset because it’s about living your life worth living. We can all relate to that. Don’t we all want that? We all want meaning and purpose and value-driven lives. And so that’s usually what I say, is, “I get it, you can feel kind of burnt out after you’ve been sitting in these classes learning about all these skills that sometimes feel really, frankly, useless, or that they don’t work.” And yet the focus I always shift back to is the idea of DBT not working is not necessarily an effective way to think about it, it’s more about, “How can I move towards my goals?” It’s very goals oriented. And basically, one of the things we say is not make things worse. So, let’s focus first on where our life is and what’s going on and what we’re wanting to address, if there’s chaotic or impulsive or self-destructive behaviors we’re engaging in, which is exactly what DBT helps with. It’s like first things first, let’s not make it worse. Then you kind of layer into it.

Host: It sounds kind of like a practice.

Katy: Yeah, absolutely. It’s a building a muscle, really. When you go to the gym and you want to learn how to– or you want to just lift heavier weights or you want to increase your cardio capacity, whatever it looks like, you can’t do that overnight, it won’t– if you work too hard, you’ll just actually make your body shut down, right? So, build it, practice it, keep an open mindset, and I can almost guarantee it would be helpful. Maybe not all of it, but there’s going to be something in there that’s going to help you move forward.

Host: Earlier you also used that phrase layered, “DBT is layered.” And that might be a good place to revisit that here, especially with this visual I’m having of this is a rotating– when someone’s first learning these skills, there’s several meetings every week, you’re coming into a group, some people might know more than you do. What does the layered aspect mean to you, and then how do you take that beyond the care that you receive? How does it not just evaporate once you leave?

Katy: Sure. So, your first question is a good one, if I can clarify what I mean by that, by layered. I mean that while DBT does kind of immediately and directly offer skills for managing and regulating emotions and improving and maintaining relationships, building your muscle, again, of mindfulness, it can look different as you move through treatment based on what you need. If you’re coming in needing to really address self-harm, suicidal thinking, things that are potentially life-threatening, put the first things first. And then as you get these things more under control and have more skills, moving into looking at what your relationships look like, for example, looking at what your past and family dynamics, maybe traumas that one has experienced. By gaining the kind of skillset to regulate your emotions and have more coping strategies, it actually opens up for a lot of people a new way to address their suffering. And you take the DBT, you can use that, and you can also– you can go different path, you can come back, you can add it, you can focus. It’s adaptable to whatever it is you’re needing when you want to focus on therapy or treatment or making your life more worth living.

Host: It comes back to that– that’s that rally cry, that core message, making life worth living.

Katy: It always– sometimes I say it and then I’m like, “Wow, that’s so cliche.” [laughter] And yet if you sit with it for a minute, that’s common humanity there. We want to have a life worth living. When we don’t, what’s the point? People can get stuck in that. And so, we start there.

Host: I love it. And anything else you want to add on? Just that second part of that question, I’m curious about how do clients continue to use DBT outside of treatment? How do they take this home go back to maybe old things that might not have been around during treatment? How do you make sure it sticks?

Katy: Well, I think that question is a very good one and a little bit hard to answer but let me give you my best shot. So first, it’s a dynamic kind of treatment, DBT. And so, it’s not linear progress– progress in general in life, whether it’s in therapy or other ways, it’s not linear. So, you learn the skills and you have your workbook, — I always suggest to people, “Keep everything that you’ve been doing, you’ll do the worksheets over and over again, you really get familiar with them and learn the skills.” It does take practice and it does take keeping up with the framework of lots of self-assessment and a mindfulness practice. One idea is to stay more in a DBT group to look to find a therapist who either specializes in or is familiar with and can utilize DBT when you move out of our intensive outpatient programming. And I think building a community, maintaining a community of people who are like-minded. It doesn’t mean you’re all kind of sitting around talking about DBT all the time [laughter]. But the idea of being self-aware, mindful, nonjudgmental, and focusing on building relationships that support that, I think that’s where the real long-term success can come in, is get things under control and then focus on the interpersonal effectiveness skills, which is a whole module of DBT. And so, one last thing I’ll say is that two, you don’t do DBT once, a course of DBT or a treatment and just leave it behind. It’s always available. So, a lot of– we’ll have actually a lot of clients come back to the outpatient program saying, “I did your program a year ago, two years ago, I found it really helpful. I’ve kind of slid back into old patterns of behavior and maybe something traumatic or a crisis or a loss happened in my life, I really need to kind of come back,” and we’re always here for that. Happy to have people back and see that it’s always there, it’s always there for you. So that’s kind of what I think about taking it with you and making it a part of your mindset versus just a kind of thing you learned and put it kind of away.

Host: Right. That makes sense. I really appreciate you taking the time to share, and I’m looking forward to connecting with you again soon. So, in the meantime, what’s a good way for someone to connect with you and your team?

Katy: If you’re thinking you might benefit from this type of treatment, or your family member or a loved one thinks, “Yeah, I want to kind of look into that more,” the best way is to connect with our admissions department. They are very knowledgeable, very helpful, very available, and they can take you from there. And we’d love for anyone who’s finding this might be a helpful treatment, for them to please reach out.

Host: Excellent. Thank you so much again, I appreciate it.

Katy: It was great talking with you, thank you. [music]

Host: Thanks for listening to Conversations at Clearview. Please be sure to follow, rate, and review the show wherever you get your podcasts. If you or someone you love is looking to turn second chances into new beginnings, start your journey at odysseybehavioralhealth.com.

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