SPENCER: Shireen, welcome.

SHIREEN: Thank you. Thanks for having me.

SPENCER: So suppose someone goes to a therapist and they find it doesn't work, should they then conclude that therapy doesn't work for them?

SHIREEN: Absolutely not. This is a big pet peeve of mine, actually, because I think that most people don't get quality therapy. If therapy doesn't work for them, or if they think therapy doesn't work for them, that could be a problem with the match between them and their therapist, or with the type of therapy that the therapist is doing.

SPENCER: There's some debate in the field about how much the quality of therapists matters separately from the type of therapy. Do you think that in terms of quality, people often get therapists that are just not very good at doing their job?

SHIREEN: I have to be wary of not sounding very judgmental when I talk about my own field. What I will say is that most therapists have not been well trained. There are many different ways that a person can become a therapist and get a license to practice therapy, and not all are created equal in terms of whether that person has received training and experience in what I call the evidence-based therapies, mainly cognitive behavioral therapies.

SPENCER: One thing we could ask about is the efficacy of the different types of therapy, but a separate question is the quality of the therapist. Do you think a lot of people work with therapists that are just not very good at their jobs?

SHIREEN: I want to be careful not to be judgmental of my fellow therapists out there in the field. What I will say is that there are many different ways that somebody can get a license to practice therapy in their state or in their country, and not all are created equal in my mind, in terms of whether they've been trained to deliver the best possible therapy that has the best evidence for its use.

SPENCER: So there's, on the one hand, are they using evidence-based therapy? But then there's also how high quality was their training in order to execute that? Because if you go on psychology today, you'll find that everyone's an expert in all sorts of therapies, or at least they practice them. Sometimes they'll list 15 or 20 different types of therapies. It's a bit hard to believe that they're really an expert or have really good training in all those different types.

SHIREEN: I agree with that, and I actually advise people that I feel that's a little bit of a red flag when somebody lists so many different types of therapy, especially when they're different therapies in terms of different approaches. So it's one thing to list five different types of cognitive behavioral therapies for different problems, but you often have people who say they do cognitive behavioral therapy, and they also do psychoanalytic therapy, and they also do systems-based therapy, and to me, that is a sign that they are not fully in a treatment that is likely to be effective. They're a little bit too scattered in their approach.

SPENCER: But some people would say, "Isn't it good to have multiple tools? Don't you want to learn as many tools as you can, and then bring the right tool for the right job?"

SHIREEN: There are a couple of different problems with that, in my opinion. One is that there are no studies that have looked at all these different tools together. There are no studies that have looked at a therapist who has a million different strategies from a million different approaches. Do they do better than someone who just sticks to one approach? We don't have any studies like that, so we can't say with certainty that it's better. The second reason why I think there's a problem with that is that many of these therapies have different worldviews that inform them, and if you are using strategies from a variety of different approaches, you are not consistently following a specific worldview. In my mind, that means it's going to be really hard to make comprehensive changes and help the person reach their goals effectively.

SPENCER: I wonder if you would disagree with this or agree with me, but I feel like sort of the base of therapy, the bare minimum, is someone who's empathetic, who will listen to the challenges you have, things that you may not feel comfortable sharing with other people in your life. There's likely some value just for that basic thing, having someone empathetic to listen, to hold space for you, but we can do significantly better than that. If you bring the right tools, you can build on that base to get more efficacy.

SHIREEN: In the psychological literature, or the studies on this, we would call those common factors. What are the common factors across therapies that we think are necessary for therapy to be helpful? What's referred to as the therapeutic alliance, the relationship between the therapist and the client, is considered a common factor. How well you feel supported, how much you enjoy working with that person, and other things like listening as a therapist and providing validation and empathy would be considered common factors. Common factors are really important and a foundation, I would say, for the effectiveness of treatment. For some people who don't have a lot of severe difficulties or problems, that might be sufficient. I go into a therapy session, I talk about what's bothering me, I get warmth and support and validation, and I feel better afterward. In that sense, therapy was helpful for me. When people start to have greater mental health problems or problems that interfere with their functioning, just having someone to talk to is often not sufficient.

SPENCER: Some people argue for the so-called dodo bird hypothesis, which is the idea that whatever therapy is practiced, they all work about equally well when you actually pit them against each other. It's really not about the therapy at all. It's really just about the attributes of the therapist. What do you think about that view?

SHIREEN: This was talked about widely when I was coming up in grad school, the dodo bird hypothesis and the controversies that that led to. I think a couple of things. It is really hard to study the effectiveness of therapy. We call this kind of psychology a soft science because we do our best to be as rigorous as we possibly can in our trials, and there is so much variability in anything that we do when we're trying to study the effects of therapy. That's a challenge in this field. How do we decide whether therapy is effective or not, and for whom it's effective? That is a really big challenge. I think there have been enough studies after the dodo bird hypothesis came out to suggest otherwise, to suggest that manualized treatments, treatments that have been studied and implemented and are based on psychological science, are broadly speaking, going to be more effective than therapies that aren't.

SPENCER: And by manualized, do you mean essentially therapies that are standardized, where you could say, "Here's how to do it? You can read this book. It's not sort of like the therapist figuring it out as they go."

SHIREEN: Yeah. Most people don't know that that even is a thing. Most people, meaning consumers of therapy, don't know when they've been struggling with depression, that there are a number of manualized treatments that have been found to be effective for mild to moderate, sometimes severe depression. That's one of the things that I think interferes with therapy being effective. Getting back to your first question, is the therapist even saying to the client, this is the type of therapy I do? You have this problem, I'm going to approach it with this treatment because this treatment has been found to be effective. Most therapists, in my mind, don't do that, and so the client is left not knowing that those treatments even exist.

SPENCER: I wonder if some people don't like the idea of manualized treatment because it sounds less customized. But as I understand it, just the fact that it's manualized doesn't mean there's not a lot of choices that the therapist is making. It's just that the whole structure of it is standardized. But surely, the therapist is constantly making small adjustments based on what's happening in the session.

SHIREEN: For sure, and certainly, as therapists get more experienced with whatever treatment they're doing, they make it their own. They learn about how to apply it. So for example, a standard example might be cognitive therapy for depression, in which we help people learn to evaluate their interpretations or thoughts and work on changing their interpretations or thoughts in order to affect how they feel about something. So my husband makes a mess in the kitchen and then leaves for work. If I have the thought he's so disrespectful towards me, that's going to lead me to feel a particular way. If I have the thought instead, "Oh, he must have been in a rush this morning, then I'm going to feel differently, right?" So the way we think about something affects how we feel. So cognitive therapy, if somebody were to be doing cognitive therapy for depression, the therapist would flexibly talk about what your interpretations are with regard to a situation, what are some alternatives for how you could think about it, and how does that affect how you feel? That would be what the manual says. But of course, in any given session, it's going to look quite different depending on what that conversation yields.

SPENCER: Sometimes, when I have friends that go to a therapist and they're like, "Oh, it didn't really work," I like to ask them follow-up questions that help assess whether they really got the therapy that they thought they were getting. And so if they went to someone who claimed to be practicing cognitive behavioral therapy, I'll ask them, "Well, did you get homework?" Most of the time they say no, which to me is shocking because I don't think that it is really cognitive therapy or cognitive behavioral therapy without homework. It just seems to be such an integral part of the treatment. Similarly, I ask them, "Did you have a clear goal that you agreed on with the therapist, and then did the therapist keep bringing the sessions back to that goal? Or did the therapist kind of make every session about whatever you felt like talking about that day?" Often again, they will say, "Oh, yeah, no, it just kind of was whatever I felt like talking about that day," which, to me, also doesn't really represent cognitive behavioral therapy.

SHIREEN: I agree with you 100%. I think this is a big problem. The other fascinating thing about therapy is that this all happens behind closed doors, with just two people in the room, and therapists can drift quite a bit from what they want to do or quite a bit from the manual, and there's just no oversight of that. It's kind of a fascinatingly messy field.

SPENCER: What's your read on the evidence in terms of what types of therapy you think are most proven? Keeping in mind, of course, there could always be therapies that are even better. There's just nobody bothered to study but in terms of what's been studied, what's your reading of the literature.

SHIREEN: For any particular problem, or just in general mental health problems?

SPENCER: Let's say depression and anxiety, and those are two of the most common ones people go to therapists for.

SHIREEN: Yeah, so I would say pretty clearly, for cases of depression and anxiety, cognitive behavioral therapy, or CBT, is definitely the most studied. So of course, there is that caveat that other treatments have not been studied as much as cognitive behavioral therapy. However, the studies that have been done on cognitive behavioral therapy for depression and anxiety show that CBT outperforms treatment as usual, meaning nonspecific therapy almost always. Now, the question of whether therapy is enhanced by medications — or more effective than medications — is a different issue. The evidence varies depending on the specific problem and its severity, but if we're talking about moderate levels of depression and anxiety, we would want somebody to have CBT. I would want a family member to have CBT.

SPENCER: I'm not sure what it's like in other countries, but in the US, I think there's this very strange phenomenon where it's almost like the luck of the draw of who someone happens to see first. If they see a psychiatrist, they end up with medication. If they see a therapist, they end up with therapy. Nobody is making that decision in a thoughtful way. Then, depending on which therapist they happen to see, they get a totally different treatment protocol. It seems so bizarre. You wouldn't expect this to be happening at the doctor where, depending on which type of doctor you go to, you get a totally different treatment.

SHIREEN: I agree, I think this is a major problem with our healthcare system. It is not integrated, and that is especially true in the private practice realm, where people seek out a private practitioner for therapy or a psychiatrist. It's better when people are seen in the context of systems where psychiatrists and mental health therapists talk to each other, but for most people, that's a major issue. Not only that, but let's say you're wise enough to get a psychiatrist and a psychologist. It is often the case that they never talk to each other, so there's no integration or communication about what might be most helpful for you.

SPENCER: One thing that people might wonder about is, okay, if an antidepressant works for your depression or anxiety, and going to therapy works, is it just much easier to take the antidepressant? Isn't it sort of the simple solution? Of course, some people are averse to taking medication, but maybe there's something to that argument. I'm curious to hear what you think about that.

SHIREEN: In some ways, I feel like doing what works. If medications work for you, if you are busy with kids and a job and all sorts of other things, taking an hour a week to do therapy is a big expenditure of time, and it certainly is a lot easier to take medication if that's what you want. The issue is that what we have seen with studies is that the effects of medication only last while you're taking the medication, and maybe that's fine for people who don't mind being on medication for the long term. But in studies that have looked at giving people medication for depression, it works, but then you see what happens when the medication gets taken away; the person's depression tends to come back. From a psychological point of view, that makes a lot of sense because they didn't learn how to respond differently to their depression. Therapy teaches people tools to change how they behave and respond, and those would, in essence, be longer lasting because even when they stop therapy, it's presumed that they still have the tools and the new behavior available to them.

SPENCER: I'm certainly not opposed to people taking medication. I think when people have really severe mental health challenges, they should look into it. It may actually help them get to a good place. It may even support therapy and be additive on top of therapy. I will say, though, sometimes it makes me a bit nervous when people jump just to medication when there might be things in their life that really need changing. So, take someone who's in a really abusive relationship and then you slap some SSRI antidepressants on top of that. That's not really the right way to handle it. A psychiatrist, not that they would do that purposely, but they're just much less engaged with what's going on. They're treating it like a medical issue, whereas a therapist, hopefully a well-trained therapist, will understand more of the context about what's going on.

SHIREEN: Yeah, and help you solve your problems. Help you respond to the situation at hand to prevent further problems from developing. How do we get you out of that relationship? Or how do we help you change that relationship so it's not abusive anymore?

SPENCER: I would also add that unfortunately, antidepressant medications can have pretty severe side effects for a lot of people, and they were kind of underestimated for a long time, probably because drug companies didn't really want people to be so aware of it. Some people take them and they just feel great and there are no side effects, but it's just something to be aware of. That being said, I think therapy can have its own side effects too. So it's not that it's purely harmless. What do you think about that?

SHIREEN: I agree. I think that often therapy brings up memories or experiences or shame about something that a person would really rather not be thinking about or talking about. There can be side effects in that way. The person might talk about something deeply shameful in a therapy session, and then they leave the therapy session and still feel ashamed and awful. I think the elicitation of emotion that comes up with therapy is going to be challenging. I also think there are challenges to engaging in new behavior and learning how to do something new. It's not easy, nor is it a linear process.

SPENCER: Let's talk about Dialectical Behavioral Therapy, also known as DBT. What is that and what's its relationship to CBT?

SHIREEN: Yeah, so DBT is actually a form of CBT. The original manual of DBT that was written by Marsha Linehan is called Cognitive Behavioral Therapy for Borderline Personality Disorder. We believe that DBT is very strongly a form of cognitive behavioral therapy, and it has some added components to it. In traditional CBT, which was developed and studied extensively starting in the 1970s and 1980s, the focus was very explicitly on how to change your thoughts and behaviors so that you can feel better. When Marsha Linehan, who developed DBT, applied this model of CBT to the population she was most interested in, which were people who were suicidal and also met criteria for a disorder called Borderline Personality Disorder, she found that emphasizing change so strongly actually led to a lot of negative reactions from the clients. The reaction was, "If I could change all of these things, I would have already. You don't understand that my problems are bigger than that. There's so much more to it; it's not that simple." This happened so often with her that she realized standard CBT was missing something. In her iterative development of the treatment, she first decided it was missing acceptance, meaning instead of striving to change everything that's a problem in your life, maybe what we have to learn to do is accept our life and accept our problems. This problem is so big; it involves so many people and circumstances that changing it is going to be monumental. Instead, maybe just accepting it is a way to go, or we can't possibly change it. For example, I have a client who is struggling because there was infidelity by his spouse in his relationship, and he's very stuck in the feeling that it shouldn't have happened. Anyone who's been in that situation might find themselves thinking, "This shouldn't have happened. This was wrong. This has ruined everything." And you can't possibly change what has happened in the past. Even if the past is a second ago, you can't change what has happened. So what do you do in this circumstance? What do you change? You can work on changing how you think about it, but maybe your thoughts are actually quite valid. Instead, you could focus on, "I have to accept that this happened. I don't like it, but I have to accept that this happened." This focus on integrating acceptance into standard cognitive behavioral therapy was one of the major advances of DBT that added to traditional CBT. The other component of DBT that kind of separates it is referred to in the title of Dialectical Behavior Therapy, which is striving to have a dialectical balance between change and acceptance, so that we're not doing only change in therapy, where everything has to be fixed and changed, nor are we doing only acceptance, where your life is miserable, but that's the way it is. We're trying to balance those two: what do we have to accept, and what can we change? And how do we change it?

SPENCER: We did a whole episode on Borderline Personality Disorder, so I'd recommend looking that up if you're interested in that topic. But people might wonder, "Okay, how is this relevant to me? It's a treatment for Borderline Personality Disorder. I don't have that."

SHIREEN: Yeah. I think that's a really valid question. In fact, I often talk about this because it's like, how is this treatment that was developed for this severe problem relevant for anyone? I think it is, and I think it is for a few reasons. One is that the premise of DBT, or one of the assumptions of DBT, is that the problems we experience, or mental health problems we experience anyway, are a result of emotional dysregulation. When we have strong emotions, when we feel like we don't have a lot of control over them, that leads to problems. Those could be problems in terms of behaviors; I lash out at somebody, or I drink or use substances, or I engage in other impulsive behaviors as a way of managing my emotions. Or it could cause problems just because we feel bad when we have emotions all the time, and we feel strong emotions that we can't control. We just feel miserable. Because that's an assumption of DBT — that our problems are related to emotion dysregulation, I think most people can appreciate that there are aspects of this treatment that could be relevant for most people. Another assumption of DBT is that the reason we struggle so much is that we haven't learned how to do things differently. Put another way, it's a skills deficit model. "The reason I'm depressed is that I haven't learned how to activate myself when I feel sad, or I haven't learned the skills to develop meaningful relationships. The reason I have anxiety is that I haven't learned how to respond differently when I get nervous or how to do things in spite of my anxiety." If we have that mentality of a skills deficit model, then the approach of DBT is to teach people things that we presume they don't already know. That's the skills component of DBT that we have found to be widely accessible, widely used, and widely appreciated across problems, disorders, etc.

SPENCER: What other conditions are there now randomized control trials showing that DBT helps with?

SHIREEN: Because of those things that I just said about why DBT is relevant for so many problems besides borderline personality disorder, very soon after the initial study on DBT was published, other psychologists and researchers started to see that, "Oh, this treatment could actually be useful for the population they work with, because they have emotion dysregulation and skills deficits." The earliest adaptations of DBT were actually for eating disorders, such as bulimia and binge eating disorder, because the people studying that said this is clearly a problem of emotion dysregulation for a lot of people, that the binge eating episodes and the compensatory behaviors are efforts to regulate their emotions and actually work to regulate their emotions very well in the short term. DBT was adapted for people who had eating disorders. Then it has been looked at for teenagers with borderline personality disorder features or teenagers with bipolar disorder. It's been looked at for people with depression and anxiety, specifically the skills group. It's being looked at for people now who have autism. You name the problem, and there are probably studies looking at how DBT can be applied for that.

SPENCER: You say looking at, but do we have the results of these trials yet, or is this more emerging research?

SHIREEN: It is an emerging field in the sense that these adaptations are being studied every day. I will say that over the last 15 years or so, NIH and NIMH, which have been the predominant funders of trials in the US on psychotherapy, have de-emphasized studies like the ones I'm talking about, which is, "Can we apply DBT for this population or that population, in favor of other kinds of research?" Because of that, what we see instead are a lot of pilot studies, small studies, uncontrolled studies. With those caveats in mind, I will say that the research on DBT, and in particular on DBT skills, generally shows that they're effective at reducing the problem for which the person is seeking therapy, whether that's depression, bipolar features, eating disorder symptoms, etc.

SPENCER: If someone's asking me for advice about what type of therapy to pursue, I usually recommend they start with cognitive behavioral therapy for depression and anxiety. But if I think that strong emotional regulation is an issue for them in particular, I will recommend DBT as a starting point instead of CBT. That sounds aligned with what you're suggesting as well. Is that right?

SHIREEN: Yeah, I think so. The way I think about it is we tend to think about cognitive behavioral therapy as being relatively short. In practice, I don't think that's so much the case because if you like your therapist and you feel like it's working for you, then you stay with that person. But we have developed CBT to not be a lifelong therapy. I think about it as if I think somebody can benefit from a few sessions of CBT, absolutely, I will recommend that. Why have somebody do more than what they need to do? But if I feel like either emotion regulation is a significant problem for them, or they have behaviors that are more serious, or they have tried therapy and it hasn't been so effective in the past, those are all reasons why I might think about DBT over CBT.

SPENCER: Before we get into more about how DBT works, I want to address something that I think sometimes rubs people the wrong way, both with CBT and with DBT, which is that it centers the person's problems in their own mind or in their own skills. A common reaction people have is, "No, I'm in an objectively difficult situation. I'm depressed because the world sucks," or "my world sucks," I do think that these kinds of therapies can sometimes come across as though they're saying, "Oh no, it's all about you. It's all about your lack in some way." How do you respond to that?

SHIREEN: This is something that I think DBT in particular really emphasizes, which is the importance of validating that those are objectively difficult circumstances. The question, though, is what do we want to do about it? One of the assumptions in DBT is that you haven't caused all of your problems, but you're the one who has to solve them. I think that kind of speaks to that point. The reason you have the problems that you have, or you feel the way you do, is because of a million other things, including difficult things that are happening in the world. You, though, are the person that has to change the problems that you're experiencing. I think that does trip people up sometimes because they come in and they want everybody else to change. Trust me, I get that. I would like that too. It's just not how it works, unfortunately.

SPENCER: I think it's also interesting because people with borderline personality disorder are often suffering so much and are so dysregulated that it's cool because it sort of means these techniques are tested at a really extreme level. Many of the people who might benefit from DBT, the technique is for them, is going to be used on maybe a less challenging challenge, if you will.

SHIREEN: Yeah, as a therapist, I think that is nice to have sometimes, but I often find now that I've been doing this for so long that I'm used to the more severe problems that when somebody comes to me personally with less severe problems, I'm like, "Oh, what do I do with that? I need the more severe problems to feel like I can be most helpful." That's just a me thing, I think.

SPENCER: Being someone who treats borderline personality disorder, I imagine it's very challenging. I've talked to other therapists who have told me patients threaten to kill themselves all the time. Patients can be extremely disruptive during the sessions. So maybe you could take a moment to talk about what it is actually like working with this population?

SHIREEN: Yeah, I'll speak to that and then also say how DBT actually addresses this. Because it is a very stressful undertaking to say, "As a psychologist, as a therapist, I want to work with people who are constantly on the verge of dying by suicide or self-harming or doing these risky behaviors." There are probably all sorts of analogies in different professions — why do some people go to medical school wanting to be neurosurgeons, and others choose, I don't know, family medicine or something? I think it's probably a personality trait within some of us as to why we want to work with people that are more severe. Personally, I find it incredibly rewarding because I feel like I can make a real difference in people's lives. That said, there is, of course, high risk and rates of burnout and fear and anxiety and stress when working with these populations. In DBT, we have something for that, which is what we refer to as the consultation team, where DBT therapists, if they're doing DBT, truly doing DBT, go to a weekly meeting of other DBT therapists on their team. The purpose of that team is to help improve therapist skills and capabilities, reduce burnout, provide support to each other, provide help and guidance, and take a team-based approach so that as a DBT therapist, I don't feel like I'm the only one treating this intensely suicidal person. I know that I have my team helping me to treat them.

SPENCER: That makes a lot of sense. It brings needed support. Are there other challenges you think are unique to working with borderline patients?

SHIREEN: Well, I think traditionally, the stereotype, which is sometimes borne out, is that people with borderline personality disorder have a lot of trouble in interpersonal relationships. Actually, that's the diagnostic criteria. They have lots of ups and downs in their relationships, and their relationships are very chaotic. In treating someone with borderline personality disorder, you are now part of a relationship with them, and the problems they experience in their relationships are going to show up in their relationship with you. That's inevitable because they have emotion dysregulation; they don't have the skills to manage emotions. So how does this show up? It could show up with clients calling you too much. I once had, this was years ago, a client drive to my house and park outside my window. She didn't do anything; she just sat outside my house. But that was alarming enough for me to call someone on my team at that time to get some help. Also, they could get angry in session and yell and scream and threaten, because this is the nature of the problems they have. As I said, of course it's going to show up with you, and that obviously makes things challenging as someone who is trying to help them.

SPENCER: So let's jump now into talking about the actual skills that you can learn from DBT. You mentioned this idea of a dialectic. How does that come into play? How can we use that idea?

SHIREEN: Dialectics are everywhere in the skills. What I mean by that is that in the skills, you have some that are focused very explicitly on change. How do you change your behavior? How do you change your thoughts about something? Then you have skills that are focused on acceptance. How do you accept the reality of this moment, whether you like it or not? How do you accept and be mindful and present in this moment fully? In that way, dialectics are infused throughout. You also see dialectics in specific skills, like how do you think about something non-judgmentally? Instead of immediately going to one end of black-and-white thinking, how do you incorporate other aspects of what's happening to have a non-judgmental interpretation of the situation? We talk about all these skills in our book, Real Skills for Real Life. There's another skill called "check the facts," which has to do with checking to see if your thoughts or interpretations fit the facts of the situation you're in. That is really teaching us to take a more dialectical approach, to see things as more complex than just right or wrong.

SPENCER: Is it fair to say a dialectical is when you have two truths that you're holding at the same time that seem like they're in contradiction?

SHIREEN: Yes, and I would say in the treatment, we're also talking about being able to recognize that we are on one side, having a fixed thought about something, and by realizing that we're only on one side, that allows us to open up and see that there might be other ways of thinking about this.

SPENCER: It's interesting because it's almost a critical thinking skill where people get stuck on one viewpoint and have the absence of an alternative viewpoint.

SHIREEN: Yeah, exactly. I think this happens to us all the time. We get mad about something when we're driving and somebody cuts us off, and we think, "What a jerk, how dare they? They're so rude. They don't care about anybody else. They're going to cause an accident." We get so quickly into our ruts about how we think about something instead of even considering that there might be another possibility, or that we can't possibly know what's happening with that other person.

SPENCER: You give a really interesting example of, on the one hand, your feelings are real and valid, and on the other hand, your interpretation of the situation might not be accurate. I feel that's actually a kind of dialectical that comes up almost universally.

SHIREEN: Yeah, for sure. Even the example that I gave, which is a minor one, with my husband leaving everything a mess. When I come down and see the mess, the feelings of irritation are a valid response to seeing the mess. How much I feel that is also influenced by my interpretation of that. If I can move towards saying, "Oh, he must have been in a rush, and I've left the kitchen messy before, and I love him and I'm willing to tolerate all of this," then it's not that my irritation isn't valid; it's that it doesn't consume me anymore.

SPENCER: I think some people feel that if they accept that their interpretation may not be accurate, they have to give up on the idea of their feelings being valid. So where does the validity of feelings come from, if not from the accuracy of the interpretation?

SHIREEN: Well, I think it comes from all sorts of things. One is that it comes potentially from our learning history, right, our prior experiences that have led us to think or feel the way we're feeling. Let me give an example of somebody who has once been mugged on the street in a way that was very scary. Okay, so they've been mugged on the street in the past, and now they're walking down a dark street and they feel afraid. We would say that their fear is valid in the sense that, of course, you feel afraid; you have had a very traumatic, scary thing happen to you on a street when you were walking by yourself. On the other hand, in this situation, let's say you're in a safe place; you know there's no reason to suspect that something awful will happen to you. Others might say, "Your fear is not valid; get over yourself." It's not scary or something. So that's what we're talking about. It's like, how do we balance those two things? Of course, you feel afraid because of this thing that has happened to you in the past. Is it possible that you don't need to feel afraid right now? The threat is not there right now. We want to do both. We don't want to say, "Therefore, it's not valid for you to feel fear or don't feel fear." We want to validate and then also assess, does it make sense at this moment for you to feel that way?

SPENCER: I think another dialectical that comes up almost universally with people is this idea, "I'm good enough as I am, but also I could be better, or I could change, or I could improve the situation." How do you think about that dialectical?

SHIREEN: I think that those of us who identify as ambitious or goal-driven always have these thoughts of, ""There's so much more I should or could be doing. I didn't exercise as much as I wanted today, or I didn't eat as well as I wanted." We are often judging ourselves against a standard that we can't always live up to. So I think we're thinking about that in a way of, "Am I actually invalidating myself? Am I refusing to accept myself in the situation that I'm in by constantly striving to change, and by doing so, is that actually making me miserable or unhappy?" So that's really what I'm thinking about: "Am I unhappy? Am I miserable? And if so, what do I need to change about what's going on here? Do I need to be kinder to myself? Do I need to validate myself? Do I need to say it makes sense that I feel this way? Or do I need to say, 'I've been trying to accomplish this goal for three months and I haven't made any progress. What do I need to do to increase the likelihood that I'm going to meet this goal? What's one small step I can take?'"

SPENCER: It seems to me that sometimes these seeming contradictions get resolved by having a clearer definition of the thing, or a clear sense of where the thing drives value. The idea that you're only valuable if you change and become better is inherently going to always leave you feeling like you're not valuable. If that's where you get your self-worth, you're kind of putting yourself in a pickle. But if you can understand that you can derive self-worth from something else, then that can resolve the tension.

SHIREEN: I think that how we feel about ourselves is dependent on so many factors, not just what we achieve, but also how we treat other people, how we treat ourselves. The phrase in DBT is "developing a life worth living," and that was developed with suicidal people in mind, meaning that if you develop a life worth living, you no longer feel like killing yourself every moment of the day. But I think there's something of value in that phrase, even if we aren't suicidal, which is, "What is a life worth living?" For me, it often translates to living in accordance with values that I have, not being perfect at any one of those things. The value that I have could be that I am always striving to achieve something new, and that's okay. That's perfectly okay as a value. Am I living in accordance with that value? Does that create a life worth living? Or am I driving myself crazy? Am I miserable because I'm constantly striving? Then maybe that's not the value that is making my life worth living.

SPENCER: Earlier in the conversation, you briefly mentioned acceptance. Let's dig into that a little more. What is radical acceptance and how does it relate to the suffering we experience?

SHIREEN: Radical acceptance is a DBT skill, and in essence, it's completely and totally accepting this moment or this situation exactly as it is, recognizing that it is what it is because of a million moments that led up to this. The most radical thing you could say is, "This moment is perfect as it is." That would be a form of accepting it and maybe changing the way you think about it a little bit, saying that, "This moment could not be any other way than what it is right now, so I'm going to radically accept it." How does that relate to suffering? We distinguish a lot between pain and suffering. Pain is inevitable. Pain is a part of life. We're all going to feel pain, and a lot of the problems we experience come when we try to escape pain, because we often try to escape pain in pretty ineffective ways. Pain is an inevitable part of life, and we often add to our pain when we refuse to accept something. It could be you had a difficult childhood that was incredibly painful, and lots of bad things happened to you. Now you're no longer a child; you're an adult, but you spend a good deal of your time thinking about how terrible your childhood was, or if only your childhood was better, or if only your parents were different. All of those thoughts and ruminations are actually evidence of non-acceptance, because you are trying to change or control something that you have no control over anymore. This is all in the past, so we are actually adding to the pain. The pain of having a difficult childhood is now compounded by our suffering. By saying, "Why me? Why did that happen to me? It should have been otherwise," etc. Instead, radical acceptance would be, how do you accept the pain and challenges of your childhood without adding on your suffering?

SPENCER: There's this idea that people sometimes use the second arrow. You get hit with one arrow of some bad thing, and then the second arrow is when you shoot it at yourself, because the way you react to it actually gives you a lot of extra suffering. It's not necessary.

SHIREEN: Yes, and of course, we also want to validate that. Of course you're going to do this, because we all do this. We all have thoughts that this shouldn't have happened, it should be another way, or I wanted it to be another way. But I think the challenge here, or the task, is to figure out what am I doing that's actually adding to the pain, and how can I reduce that?

SPENCER: I would argue that sometimes acceptance can even reduce the primary pain as well. I don't know if this is an idea in DBT or not, but just to give an example, let's suppose that you thought you had $10,000 in your bank account, and then you wake up and realize you miscounted. It's actually 9,000. You misremembered. You're going to feel somewhat bad. But if you didn't already think you had 10,000, then you woke up and found you had 9,000, you'd feel fine. There's some way in which your expectation, the difference between your expectation and reality is what your pain is responding to or your suffering is responding to. Sometimes acceptance, I find, can change the baseline. By accepting things as they are, rather than holding up this different reality against the current reality, it squashes them together and it's like, "No, it is exactly this way. There's not a difference between my expectation and reality. My expectation is reality, and somehow that kind of reduces the suffering too."

SHIREEN: I think non-acceptance is often the rejection of reality. Once we can actually accept reality for what it is, then we will have a reduction in suffering. I agree with that.

SPENCER: Another skill that you talked about is validation. What is validation? How does that come into play in DBT?

SHIREEN: Validation falls into the interpersonal domain within the skills. There are different domains within the skills, and one of the domains is interpersonal effectiveness. How can you be more effective in your interactions with other people? One of the ways you can be more effective with other people is to learn how to validate the other person more effectively. Validation is basically expressing, communicating, understanding, and acknowledging the other person in terms of their thoughts, feelings, and behaviors. The reason we teach this as a skill in DBT and in our book is that a lot of people don't actually learn how to do this. We often learn from examples in interpersonal situations, and if you grew up in an environment where people did not model for you the expression of empathy and understanding, then you haven't learned how to do that yourself. We teach people how to validate others because that is going to make you more effective when you're asking for something or when you're saying no to something. We also expect that as we learn to get better at validating other people, we can also get better at validating ourselves, and that is something that a lot of us lack. The skill is saying to ourselves, "It makes sense that you feel this way, it makes sense that you think this way." For me, that has been a game changer. To say to myself, it's okay to feel this is the ultimate form of self-validation for me.

SPENCER: Let's do an example of a standard situation where someone might fail to get validation, and what would it look like to give validation? How would that help?

SHIREEN: You can think about it in the form of a work task. I work in a large organization with a lot of bureaucracy and rules, and many people who listen to this might relate to this. Sometimes you want to challenge a rule that is not very effective or is interfering with some aspect of your job. I could write to this person or talk to them on the phone, someone whose rule I want to change, and I could say, "This rule is terrible. Fix it." No matter what my relationship is with that person, that is less likely to be effective than if I think about how to skillfully approach the situation and include validation. It could be, "I know you have so much on your plate right now, and I really appreciate you giving some thought to this matter," or, "You must get 100 emails a day from people wanting things to be different, and here I am, your 101st." So you're incorporating validation. These are different strategies we have for interpersonal situations. The idea is that if the person feels understood by you, they're more likely to engage in the conversation with you than if they feel like you're dismissing them or not caring about them. I think that's basic, but often we forget to do that because we're in a rush or experiencing stress and emotions, and we just want to cut to the chase instead of realizing that validation is going to help us be way more effective and therefore save us time in the long run.

SPENCER: What does it look like in terms of validating yourself? What would be an example where people might typically not validate themselves, and what would the end to that be?

SHIREEN: We often don't validate ourselves. When we say to ourselves something like, "I shouldn't be so upset about this," or, "That wasn't a big deal. Why am I so upset about this? I should just be able to get over it," these are things we often say to ourselves. Perhaps somebody criticized us, or we experience something as criticism, and we say, "Why am I so upset? I shouldn't be so upset about that. I should have thicker skin." All of these "should" statements are often signs that we're not accepting and not validating ourselves. An alternative would be to say, "It makes sense that I feel this way." When you get criticized, it hurts. I could challenge that and say they didn't mean it personally. We often don't validate ourselves, so when we have thoughts like, "I should just be able to get over this," or, "I shouldn't be so affected by this," we can alternatively see what about our experience we can validate. We could say, "It makes sense that I feel this way because when you experience criticism, it's painful," or, "It makes sense that I feel this way because I experienced a lot of criticism as a child, and I never learned how to cope with it." There are many ways we can validate ourselves. Sometimes I just say, "It makes sense that I feel this way," without even coming up with the why, just knowing that there is a reason why I feel this way. Once we say that to ourselves, it might open up the possibility to say, "This other person didn't mean to be critical," or, "I know that this other person loves me and maybe now I can incorporate that and not feel so strongly about it."

SPENCER: How does validation of oneself relate to self-compassion? Is it essentially the same idea, or is there a difference there?

SHIREEN: I think they're very similar. I think self-validation leads to self-compassion. Compassion is having positive feelings towards yourself, caretaking feelings towards yourself. The more you validate yourself, the more likely it is that you will feel compassionate towards yourself. But I say the goal of validation is to feel understood. If compassion goes along with that, then that's great. It often does, but if it doesn't, that's okay, because we're really talking about, 'Do I understand why I feel this way? Do I understand the other person?"

SPENCER: It's really fascinating to me how often in communication, we're sort of rooted in our own perspective. Even just taking 30 seconds to think about how the other person is going to think about what I'm going to say can immediately increase the efficacy of our communication, making it more likely to be well received and more likely to be well understood as well.

SHIREEN: I cannot agree more. I think often we rush into interpersonal situations without giving it a lot of forethought. Again, I think that's often because we are stressed or we're in a rush or we just want to get it over with. By rushing in without thinking about the other person, we can make the situation worse and/or reduce our effectiveness. So taking the time is important. There's a skill in DBT that's also in the book called DEARMAN. The DEARMAN skill is how to ask for something or say no to something in a way that increases the likelihood of your success at getting that. One of the ways in which I think the skill of DEARMAN is so helpful is that when I'm going into a challenging interaction with somebody, even though I started learning these skills 25 years ago, I will still, when it's a really difficult or high-intensity situation, write out the steps of my DEARMAN in advance and do the prep work. By doing that, I can really think through how to be most effective in that situation, but it also slows me down from being impulsive about asking for something, which may be more likely to backfire. I think the idea of intentionally going into an interpersonal situation and saying, "Here's how I want to approach it, this is what I want out of it, and this is how I'm going to validate the person," can be incredibly useful.

SPENCER: So, DEARMAN is essentially getting you to kind of plan each part of that process step-by-step so you're more prepared when you go into the difficult conversation.

SHIREEN: Yes, actually, it helps you write out a script in such a way that you feel you don't have to memorize it 100% but to recognize, "Okay, if I want to ask somebody to do something for me, I need to describe the situation. I need to express how I feel about it. I need to assert specifically what I want from the person, and I need to reinforce, meaning, to say to the person a reward that would come up or an appreciation that would happen if I were to get the thing that I'm looking for." That's the D, E, A, R, in a nutshell.

SPENCER: The last thing I want to ask you about is you mentioned that balancing acceptance and change is the central task of living. What do you mean by that? It's an interesting statement.

SHIREEN: What I mean by that is this dialectical approach to the treatment that I do is one that I think is actually important to everyday life, which is actually very similar, in a sense, to the Serenity Prayer that's used in AA. But if we could say it is kind of taking the religion out of it, which is, what can I change and what do I have to accept? Meaning what I can't change. I think so much of our everyday suffering and misery is being stuck in not changing something that actually could be changed, or not accepting something that we have no control over. So recognizing that, in this situation that's presenting a problem for me right now, I have a choice. I can choose to accept it exactly as it is and not try to do anything differently. Or I can choose to change it, or I can do a combination of the two. Sometimes we say you need to accept it in order to be most effective at changing it. So I think we can take that approach to our everyday problems in living and just actually ask ourselves these questions: can I change something here, or do I have to accept what's going on?

SPENCER: Yeah, it's really interesting how both of these things are underutilized. I've observed that when people have a big challenge in their life, they often get used to it. At first, they may be really eager to change it, but they try some things that don't work, or they literally just get used to it to the point where they view it as part of life, and they stop trying to fix the problem. On the one hand, I think that's a big challenge. On the other hand, people have big challenges that they can't solve. Maybe they've tried everything reasonable to solve them, and yet they're still mentally rebelling against the situation day after day. They don't seem to be able to find peace and quiet in dealing with it.

SHIREEN: Ultimately, it's this feeling of stuckness. In both cases, you get really stuck in where you're at. What I would suggest is that to get unstuck, you need to approach things more dialectically.

SPENCER: What does that mean, in this case, approaching it dialectically?

SHIREEN: Basically means asking, "Why am I stuck with this? Why am I suffering here? Why am I thinking every day that this will never change, or that things are going to be miserable? What can I do about that?" If I'm stuck in saying things will never change, am I adding to the pain of this situation with suffering? Am I refusing to accept the situation as it is, or am I failing to see that there are things I can do to change the situation, and I lack the motivation or the skill to make those concrete steps? Change is hard. That's something we want to validate, too. Change is hard, and it often feels easier to remain stuck. It also feels more miserable.

SPENCER: Something I think is actually pretty empowering is that in almost any situation, there's a way that you can handle it better. Even if you can't change the situation, even if you're stuck in chronic pain, for example, and let's say there's no medical treatment, nobody in the world knows how to make the pain less. There's still ways that you can make your life better by learning to process the situation in a more healthy, helpful way. I think that's almost always true. I think that's actually really powerful. It can also be taken the wrong way, as if, "Oh, it's your fault," which it's not saying. It's just saying that there's something you can do to suffer less.

SHIREEN: Yeah, I have a similar problem-solving mentality, which is this feeling that there are solutions to every problem. The solution isn't necessarily going to get rid of the problem altogether, but there's always a different way to respond to something, and then to see what effect that has.

SPENCER: So what's an easy way that people can learn more about these skills if they found them intriguing, if they thought they might be helpful for them?

SHIREEN: Sure. The original DBT skills manual is widely available, and that was published by Marsha Linehan. You can find that it is useful for people who are in DBT therapy. I think people who aren't in DBT therapy might find it a little overwhelming. It's 225 pages of handouts and worksheets and everything. For that reason, my colleague Jesse Finkelstein and I wrote a book called Real Skills for Real Life, where we talk about some of the major DBT skills, and we teach them in user-friendly, illustrated ways that tell you how to practice, what to do, and what not to do. That's one way. The other way that I can offer people is that in 2020, when COVID was happening, we put out a number of animated skills videos that teach DBT skills, and we put them on YouTube. You can find those there. They've actually been translated into different languages, and they all exist on youtube.com/dbtru, and you can learn about the DBT skills that way too.

SPENCER: Fantastic. We'll put links to those in the show notes. Shireen, thanks so much for coming out. It's great to chat with you.

SHIREEN: Thank you so much for having me.