|
Alicia Smart, Psy.D. - Guest
is a licensed clinical psychologist in California with over 20 years of clinical experience providing evidence-based mental health care to children, adolescents, adults, and families. She began seeing clients during graduate training and has worked across community mental health, medical, and private practice settings throughout her career. Alicia earned her B.A. in Psychology and Chemistry from New York University and her Doctorate in Clinical Psychology (PsyD) from the California Institute of Integral Studies. She is a DBT-Linehan Certified Clinician and has extensive experience treating mood and personality disorders, trauma, anxiety, grief, ADHD, autism-spectrum presentations, and chronic emotion dysregulation. Her work frequently integrates DBT into suicide risk management, neurodivergent-affirming care, and complex relational systems. She is the Founder and Clinical Director of Guidepost DBT in Corte Madera, California, where she oversees a team of therapists providing comprehensive Dialectical Behavior Therapy (DBT) and evidence-based care. In addition to clinical leadership, Alicia provides training, supervision, and consultation to clinicians seeking advanced education in DBT and related approaches. Alicia is also a co-founder of TheraHive, an innovative online DBT skills and learning platform designed to make high-quality DBT education more accessible to individuals and clinicians worldwide. |
|
W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Keith Sutton, Psy.D., a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (02:19):
Today, I'll be speaking with Alicia Smart, Psy.D., who is a licensed clinical psychologist in California with over 20 years of clinical experience providing evidence-based mental health care to children, adolescents, adults, and families. She began seeing clients during graduate training and has worked across community mental health, medical, and private practice settings throughout her career. Alicia earned her BA in Psychology and Chemistry from New York University and her doctorate of clinical psychology from the California Institute of Integral Studies. She is a DBT Linehan-certified clinician and has extensive experience treating mood and personality disorders, trauma, anxiety, grief, ADHD, autism spectrum presentations, and chronic emotional dysregulation. Her work frequently integrates DBT into suicide risk management, neurodivergent affirming care, and complex relational systems. She's the founder and clinical director of Guideposts DBT in Cort Madera, California, where she oversees a team of therapists providing comprehensive dialectical behavioral therapy and evidence-based care. In addition to clinical leadership, Alicia provides training, supervision, and consultation to clinicians seeking advanced education in DBT and related approaches. Alicia is also the co-founder of the Hive and Innovative online DBT Skills and Learning platform designed to make high-quality DBT education more accessible to individuals and clinicians worldwide. Let's listen to the interview.
Keith Sutton, Psy.D. (03:45):
Well, hi Alicia. Welcome.
Alicia Smart, Psy.D. (03:48):
Thank you, Keith. It's great to talk to you! Looking forward to getting into some interesting things around RO-DBT and DBT with you.
Keith Sutton, Psy.D. (03:56):
Yeah, definitely. Well, and I know we had talked about the group practice you were taking over, Marin DBT, some years ago, and so we connected on that and we've been in touch and, and I've consulted with you and I've done some trainings for your organization. And so, I really was glad to have you on the program today because you do a lot of work with DBT. And then also the RO-DBT, which I wanna learn more about. But first, I always like to find out about how people got to doing what they're doing -- the kind of evolution of your thinking.
Alicia Smart, Psy.D. (04:32):
Wow, okay. I have to go back to probably pre-doc. When I first got exposed to DBT during my time at Marin General -- so part of the rotation there was to run a DBT group, and that was the first time I got exposed to DBT and I truly fell in love with it because it was so practical. And I love the idea of giving people real tools that they could take away and would make a difference, and it was very exciting to see people actually use some skills and report back, like, wow, I did the thing and it helped my behavior and it helped my relationship and I'm feeling better. And so then after that I did some training with B Tech with Marsha Linehan and other people at B Tech and learned about DBT. And then I made that my specialty, really.
Keith Sutton, Psy.D. (05:22):
Great. Wonderful. And so tell me a little bit about DBT and, you know, I've done some training in DBT, but for folks that maybe aren't as familiar, I'm sure everybody's heard of it, but yeah. Can you talk a little bit about what DBT is?
Alicia Smart, Psy.D. (05:38):
Yeah. So I can actually talk about it both from what kind of clients tend to seek out DBT, but also the theoretical model. So DBT has a biosocial model, and so for a lot of clients who come into DBT, they would describe themselves as emotionally sensitive. You know, they feel emotions intently, they have a slower return to baseline, right? And they just sometimes even describe feeling like they have no, like, no skin, like things just like hurt more. And when you combine that with an invalidating environment, or it may be not even that invalidating for most people, but for somebody who's sensitive it is, they wind up basically not trusting their own emotion, having big emotion. Sometimes the environment inadvertently will actually reinforce big emotion. So, unless they're having a crisis, that's when they finally get heard. Because there's a lot of, you know, ‘oh, you're being dramatic or it's not that big of a deal.’ And that can cause more dysregulation. And so for clients who would describe themselves as, you know, emotionally sensitive, impulsive, reactive, big emotions, maybe struggle with substance use, maybe struggle with binge eating, you know, have a hard time not feeling like, you know, their emotions are controlling them -- that they don't have control over their emotions. I think those are the people who most benefit from DBT.
Keith Sutton, Psy.D. (07:06):
Yeah. When I think of DBT, I think about it as helping somebody going from being reactive to more responsive.
Alicia Smart, Psy.D. (07:12):
Yes, yes. Learning that pause, right? Learning the ability to pause before the reaction. And that's why mindfulness is such an important part of DBT. It's really learning how to put the brakes on and also bring down the intensity so that the, you know, distress tolerance part of DBT, which is like, okay, your emotion is really high -- let’s bring down the intensity so you can actually experience them. So, that's the dialectic in DBT, is that we actually want to be able to not just control our emotions, but also feel them.
Keith Sutton, Psy.D. (07:41):
Yeah, definitely. Yeah. Rather than being emotionally avoidant or like suppressing them or letting them just kind of take the wheel.
Alicia Smart, Psy.D. (07:48):
Exactly.
Keith Sutton, Psy.D. (07:49):
Yeah. Yeah. And Marsha Linehan, right, first developed it and did the research on working with clients that were diagnosed borderline personality disorder, although it's been extended to lots of different situations for folks, again, like you're saying that have that common theme of the emotional sensitivity or the emotional reactivity.
Alicia Smart, Psy.D. (08:10):
Yeah. Marsha's story about forming DBT is actually really interesting, I don't know if you know it. She describes how she really wanted to work with the suicidal people who were suicidal in the hospital. Later on, she wrote a memoir about building a life worth living -- her book is fantastic. And she was one of those people actually in the hospital, and that didn't come out until much later in her career, but she really was drawn to this population that was struggling with suicidality, and she had been trained in CBT. So, she was actually trying to apply CBT to this population and was finding that it wasn't working. They felt, in a way, very misunderstood by the CBT. They didn't-- they felt invalidated by the CBT approach. And so, she kind of added mindfulness -- the acceptance strategies, to CBT. So DBT has a lot of CBT in it. It just also has a lot of acceptance strategies around mindfulness and radical acceptance and zen, which she --
Keith Sutton, Psy.D. (09:19):
Yeah. So I think, third wave CBT is what they talked about?
Alicia Smart, Psy.D. (09:23):
Yeah. Yeah.
Keith Sutton, Psy.D. (09:24):
That's great. And so can you talk a little bit about -- I know that there's the DBT groups and they’re broken down into the four different kinds of skills: can you talk a little bit about the skills group versus the therapy that's happening?
Alicia Smart, Psy.D. (09:46):
Yeah, Great. So in order to be considered doing comprehensive DBT, you need both components. So I think there are many therapists who might say they're doing DBT, and they might be doing more like DBT-informed work, which it, you know, can, for many people, be really helpful. I would say as a DBT practitioner, that for those that have suicidality and self harm in the mix, comprehensive DBT is considered the most evidence-based. And if you have high dysregulation, they're probably going to make more progress if they have both on board. The skills group is where you learn the skills. So it's usually a two hour to an hour and a half format. You're doing mindfulness to begin, and then you have home practice every week where you're practicing a skill, so you're learning a new skill each week. And then you're practicing for that week, and then you're reporting back to the group and hearing how other people are using the skills. So, there's a sense of accountability. And there's a sense of being able to learn from other people, like, ‘oh, how this is just the kind of situation where you use the skill and this is how it works.’ So it's really a great way to learn the tools.
Keith Sutton, Psy.D. (10:56):
Yeah. And it's a different kind of group than maybe a process group, is that right?
Alicia Smart, Psy.D. (11:02):
Yeah, it's considered a psychoeducation group instead of a process group. And actually, one of the things that during Covid, when we all moved online and we were no longer doing in-person -- I'd actually started a psychoeducation company with my husband called TheraHive, where we do offer just DBT skills alone, not comprehensive, but for those who maybe have a therapist but wanna learn skills, they can still do that. So ideally if you can have both, that is most effective. And for financial reasons, I mean, therapy can be expensive. Having this other option of being able to learn the tools online can make it more affordable.
Keith Sutton, Psy.D. (11:47):
Oh, great. And so there's the -- I think there's the four areas, right? There's the mindfulness, the distress tolerance, affect regulation, and the interpersonal skills. Are those kind of the four modules or what are they called? In the DBT?
Alicia Smart, Psy.D. (12:03):
Yeah. They're called modules, that's right, Keith. So we do have mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. And then when we teach families there's actually a fifth module that we kind of add in called ‘Walking the Middle Path.’ So in the regular adult curriculum, it is also included, but we include it in the interpersonal section. But for families, we spend a whole section just on walking the middle path, which is all about holding dialectics, being able to validate -- which is so important in relationships and family dynamics -- and then reinforcement, which are really important for parents, especially for adolescents with big emotions -- to be able to learn how their behaviors may be actually intermittently reinforcing things in their teen that they don't actually want.
Keith Sutton, Psy.D. (12:54):
Right. Unknowingly reinforcing. Yeah, Okay, Great. So that was reinforcement, that was validation, and the dialectics.
Alicia Smart, Psy.D. (13:05):
Yeah. That's correct.
Keith Sutton, Psy.D. (13:06):
Great. And so I learned -- I did some training in DBT a long time ago, so just to kind of check out my understanding -- I've thought about it as the mindfulness is, yeah, creating that space for that slowing things down. You know, your typical mindfulness activities to less reactivity. The distress tolerance is something to do in the moment, rather, kind of like a harm reduction strategy or something to that effect, like holding ice in one's hand rather than cutting oneself or so on. Or distraction or so on
Alicia Smart, Psy.D. (13:47):
Or self-soothe.
Keith Sutton, Psy.D. (13:48):
Yeah. And then the affect regulation, it seemed like it was kind of the things you do beforehand, like getting good sleep, exercise, like all those things to kind of keep your resources up as much as they can be. And then of course, the interpersonal skills about being able to be open and authentic and assertive in relationships. Is that kinda how that plays out?
Alicia Smart, Psy.D. (14:10):
Yeah. I like to explain it as looking at an emotional temperature when I talk to clients about it in terms of where the skills fit in. So if you think about the baseline of zero, we're totally calm, and then a hundred, I'm losing my mind, right? I'm like, motion during control. The distress tolerance skills are the ones that we're looking at using when we're at like 75 or above, maybe 60, depending on where your threshold is -- where you feel like you're no longer in control or your emotions are overwhelming. Your distress tolerance does not solve problems. Like, distress tolerance is just about getting through the crisis without making it worse. And so it really is just about reducing the intensity. Now, as I say that though, there is a section in distress tolerance about accepting reality, which is not just about surviving the crisis, but actually being with the radical acceptance that’s put into the distress tolerance section. And for many people though, I would say the crisis survival skills, like you said, the distract the self, the holding ice, (which is called a tip skill), that's just reducing intensity. But then, ideally, we're also trying to be able to accept reality and be with what is, which then we get into our emotion regulation of mindfulness to our current emotion. Can we just be with, and allow emotion to come and go?
Keith Sutton, Psy.D. (15:31):
Yeah. Yeah. That's great. Yeah. I always, you know, I did training and exposure with response, prevention (ERP) for OCD, and exposure work was really helpful. And then learning about acceptance, commitment therapy and, you know, kind of the role of emotional avoidance and being willing to go towards discomfort rather than avoiding. And I've always had a hard time kind of trying to match that up with coping such as distraction or so on. Like when do you encourage, you know, the person's dysregulated, so you're encouraging deep breathing distraction or so on, but when does that sometimes become avoidance of the discomfort and not allowing the person to kind of ride the wave and gain the confidence that I can feel strong emotions and make it through? Because I think a lot of therapists that aren't as familiar with this kind of exposure work and sometimes unknowingly reinforce avoidance by teaching lots of skills to manage, unknowingly or kind of giving the mist, we have to get rid of anxiety or these bad feelings or so on, rather than being able to actually sit with them and embrace them and lean into that and build that muscle to experience the uncomfortable emotions. How do you reconcile that?
Alicia Smart, Psy.D. (16:42):
Well, I mean, this is where dialectics come in. I mean, it is a dialectic. I mean, this is true. I feel that that is why the model talks about dialectics so much, is that we are trying to constantly do both ends, and we are doing a dance on that. So, going back to the temperature, I like to use the thermometer as a way for us to figure it out. If we're at 85 and above, first of all, we're trying to build the window of tolerance. So maybe your tolerance is, once you're at 50, you can't tolerate anything. But let's see if we can build that tolerance to 65. At the same time, if we're at 80 and you're gonna self harm, then yes, we're gonna use a skill to bring down the intensity. But ultimately the goal is to be able to tolerate the feelings and not avoid them, right? So we're constantly dancing in that area. And I do tell clients, you know, when they're like, they're checking off their diary card and they're using self-soothe and distract all the time, I'm like, ‘okay, like, let's look at that. Could that look like, I mean, great, you're using skill, but are we avoiding? Are we actually using the skills as a way to not deal with problems and emotion?’
Keith Sutton, Psy.D. (17:45):
Sure. Yeah. Yeah. And I've heard of it too as sometimes using some of those coping skills to stay with the emotion and kind of be with it rather than get rid of the emotion. Exactly.
Alicia Smart, Psy.D. (17:56):
Like the titrating. Right. Because actually DBT is exposure work; it's exposure to emotion and being with feelings.
Keith Sutton, Psy.D. (18:04):
Oh, great. You were kind of saying that distress tolerance is more like 75 and above. What are your thoughts on what's below 75?
Alicia Smart, Psy.D. (18:20):
I think that, I think that's where the emotion regulation comes in. So if we're thinking about mindfulness to emotion, riding the wave, feeling our feelings, right? But also doing things to reduce vulnerability in the first place. So you had mentioned sleep, which is a huge one, Keith. I mean, so important for so many people and very dysregulating when we don't get enough of it. And so sleeping, eating, exercise, like all of those things, taking meds as prescribed, not abusing substances. So those are part of the, and then checking the facts. I mean, there's other emotion regulation skills, like looking for cognitive distortion. So checking the facts really does come out of CBT, and by checking the facts, we're looking for a cognitive distortion. Are we being black and white? Are we minimizing? Are we generalizing? Are we being catastrophic in our thinking? Right? Sure. So those tools can get added in there. And then when we realize, ‘oh, sometimes our emotions are not based on what's actually happening, but our interpretation of what's happening.’
Keith Sutton, Psy.D. (19:19):
Yeah. Great. So yeah, so kind of that those cognitive skills are still in there, but like, again, there's a whole other kind of array of tools to be able to be used.
Alicia Smart, Psy.D. (19:29):
Right.
Keith Sutton, Psy.D. (19:30):
And in the individual therapy you know, when I did my training many years ago, like 15 years ago, one of the things that they had talked about was that sometimes, because many clients sometimes are coming in with a borderline personality disorder, and sometimes there's a lot of focus on the, the recent drama that's going on, that they, when there has been say a self-harm or, or relapse of some sort, that oftentimes kind of the focus is to address that and do some chain analysis -- looking at what led to that before kind of getting into the drama of the week almost as a reinforcement or even a lack of a reinforcement of being able to get into maybe the news of the week. And instead, first dealing with, and thus decreasing some of the behaviors, even just through that kind of process within the therapy. I don't know how much that is correct or structured…
Alicia Smart, Psy.D. (20:30):
Yeah. So you had asked me, and it kind of goes back to that other question of like the, in some ways the difference between the group and the individual therapy. So in DBT individual therapy, especially stage one, so there's stages of DBT. So stage one is all about, you know, reducing crisis behavior. Like if there's suicidality, making sure of we're reducing suicidal crises. So we often are pretty structured during that first year or first six months of treatment. Depending on what the client has going on, like if they're PTSD, we might move after we get some stabilization into exposure work or, you know, prolonged exposure work as part of the treatment in stage two. But typically we have a diary card. The client and I will talk about, okay, what are, what are the targets, what are the quality of life interfering behaviors that you're engaging in, right? So maybe I am, you know, I'm explosive with my anger. I throw things to my partner when I'm, right? I, I have, I struggle with my eating. I wind up overeating and then I go into a shame cycle. I'm self-harming, like all these things that the client might say they're doing. And so those become targets that we're looking at on the diary card. And so once we're, every week we use the diary card actually to set the structure for the session. So first off, life threatening behavior; if there's any suicidality on that diary card, we're gonna address that first. And then we would also address any self harm.
Alicia Smart, Psy.D. (22:01):
Next -- we would actually address therapy interfering behavior next. So let's say the client had been inappropriately using phone coaching. Instead of calling the therapist and getting phone coaching help for skills, they've been calling and venting. Or you're, when I'm offering the skills of the client, they're rejecting the skill and saying, ‘no, that won't work. No, that won't work. No, that won't work.’ So then we're gonna talk about that in the therapy and how that's impacting our relationship and our ability to work together. And so we're gonna resolve that. So I also encourage clients if there's anything that I'm doing that’s making it hard for them to show up, or making it difficult for them to engage, then we're gonna talk about that too. Because if we don't have a good therapeutic alliance, then we really can't do much work. Right?
Keith Sutton, Psy.D. (22:51):
Yeah, we can't go anywhere from there.
Alicia Smart, Psy.D. (22:52):
Exactly. And then the last part is quality of life interfering. So we have life threatening, therapy interfering, and then quality of life interfering, that we address by looking at that diary card. And that kind of sets the stage for the session. So, in terms of like the drama of the day or the thing that might be in the quality of life, but that might be the last thing we address, depending on what else offered on the diary card.
Keith Sutton, Psy.D. (23:18):
Yeah, definitely. So kind of having that process of kind of the priorities of what's gonna get focused on in the work.
Alicia Smart, Psy.D. (23:26):
Yeah.
Keith Sutton, Psy.D. (23:28):
And then can you talk a bit about the concept around dialectics and, and what that kind of means in, in DBT? And, you know, I know there's a huge overlap with complex PTSD, along with borderline personality disorder, and oftentimes with emotional reactivity, substance abuse, all these kinds of pieces. Growing up in that invalidating environment oftentimes can lead to some of that structural dissociation kind of black and white thinking. Can you talk a little bit about dialectics?
Alicia Smart, Psy.D. (24:01):
Yeah. So I think, I mean, this is really the premise of DBT, it's one of the things that really allowed the treatment to be flexible too. It's one thing that I really appreciate because the idea of dialectic is that we're holding two things to be true at the same time, and that there's no ultimate truth, that truth is evolving over time. So it allows us to be curious and flexible. It reduces rigidity, which I think for many clients, especially when you think about like, even, I mean, I consider myself a very regulated person. However, when emotions do get high, it is easy to see how when emotions are very activated, we become narrower in our mental flexibility. I mean, I'm sure anybody listening can acknowledge that in themselves when you have these thoughts of like, ‘oh, you never are, you always,’ that's a black and white thought, right? And so anytime you catch yourself or you notice your client saying ‘always’ or ‘never,’ right? That is an indication that up black and white thinking has shown up, right? And so the dialectics is basically a way to hold that, okay, there could be more than one way of looking at this problem and more than one way of viewing things. And that there is no ultimate ‘okay, this is the only truth,’ right? And so we become more open.
Keith Sutton, Psy.D. (25:22):
Yeah. Yeah. And, can you give an example of working with the dialectics with a client or what that looks like in practice?
Alicia Smart, Psy.D. (25:32):
Yeah. So I think this, I mean, it, there're internal dialectics that we need to hold, but then there's dialectics and relationships. And so I'll, I'll bring up one recently with a couple where, you know, there was this idea that, and we actually did a video of this, this example I'm gonna give on our YouTube channel for TheraHive, if anybody wants to learn dialectics in practice. But basically, you know, a man, he'd, he asked his wife to clean up after dinner, right? And then she doesn't do it, right? And then the feeling of like, she doesn't care about me, like indicates like in his mind, this is just a sign she doesn't care about me. Like I asked her, she didn't do it. And then getting very, very angry, right? So if I'm holding dialectics, we would challenge or kind of get curious about that thought. Is there any other possible interpretation besides she doesn't care about you? That she didn't do the dishes? Yeah. Okay. Well, she did say she was tired. You know, like, and then kind of exploring like maybe there's some other reason, maybe it's not this one thing I'm holding onto, this is the reason, as evidence. And so can I hold both truths? Like it upsets me, and I'm hurt that she didn't do what I asked her to do, and it might be totally possible that she's just tired and forgot.
Keith Sutton, Psy.D. (26:56):
Yeah. Yeah. Right.
Alicia Smart, Psy.D. (26:58):
Both things could be true
Keith Sutton, Psy.D. (27:00):
Kind of holding, at the same time, both feelings: feeling uncared for, and, at the same time, maybe it is not necessarily being malicious.
Alicia Smart, Psy.D. (27:08):
Right, or intentional, even.
Keith Sutton, Psy.D. (27:10):
Yeah. Or, or so on. And kind of holding at the same time. makes me think about, I was interviewing somebody around cognitive processing therapy and I forget what they called it, the trust star or something like that, of where you're looking at different, rather than, I can't trust this person, looking at different aspects of where you can trust more, or less, or so on and, and looking at the whole picture rather than--
Alicia Smart, Psy.D. (27:31):
To one incident. Yeah,
Keith Sutton, Psy.D. (27:32):
Exactly. Definitely. As all or none. Okay. Great. And particularly to that, that, so there's the DBT and then tell me about the radically open DBT and, and, I've heard a little bit about that and we've talked about it, but I haven't done training in that specifically. I'd love to hear more and understand the differences.
Alicia Smart, Psy.D. (27:55):
Yeah. So RO-DBT, it's pretty-- it's much newer. I mean DBT had been around in the eighties. You know, even I think Marshall Linehan started actually developing in the late seventies and had kind of published her book, I think in, in the early nineties. But I think she was kind of developing it and thinking about it for a while. But RO-DBT, I think, Thomas Lynch published his book probably in 2017 or 2016, maybe 2018, anyway, but more recently. And I went and did a training with him. And I'll admit when I went to the training, I didn't actually know what I was signing up for. I was just like, ‘oh, DBT, like another thing of DBT.’ And so I, loving all things DBT, I wanted to get trained in it. And so it is an entirely different treatment. It is not the same treatment.
Alicia Smart, Psy.D. (28:45):
It has a whole set of new skills that are not related to the DBT skills. I will say they overlap in the sense that they're both behavioral therapy. And they're dialectical in nature. And so that is why the DBT is still included in RO-DBT because it has that background. And Thomas Lynch trained with Marsha and is very well versed in DBT. So he came from a DBT background. Or he developed RO-DBT, but RO-DBT, if you think about what I was saying before, the clients who benefit from DBT are kind of under controlled in their emotions. Yeah. RO-DBT at the other end of the spectrum, is for the overcontrolled population. So this is designed for people who tend to be more perfectionistic, emotionally restrained, and they actually are really good <laugh> at controlling their emotions. But they have a hard time being vulnerable and open and expressing emotion. And so, they are also struggling, but they're struggling in a very quiet way. Typically, they might because they're not necessarily being big and dramatic with their emotional suffering, it's more internal and they may feel really lonely.
Keith Sutton, Psy.D. (29:58):
Yeah. Say more about that. Like what and how are these folks kind of coming in? Are they coming in because they're feeling depressed or they're feeling disconnected? I almost think about this as the person that's being the good soldier, whatever, just kind of pushing it down and moving forward, which sometimes aren't. Maybe the person that's like, ‘Hey, I need to go to therapy.’ Oftentimes, it is coming up in a different way.
Alicia Smart, Psy.D. (30:24):
Yeah. So, I mean, there's a couple of different ways they could be coming in. I mean, some people with an OC presentation might resort to more extreme OC behaviors like OCPD. In which case it would be like more visible to other people, or anorexia, I think. Another obvious one where they do tend to be more overcontrolled and they do wind up in therapy, not because necessarily they wanna be, but because they're underweight and they're referred to therapy. But yes, chronic depression is also a big one. Because if it does go on and we feel more isolated and disconnected, it does create a feeling of being depressed. So even though, yes, they're, you know, meeting all their markers, they're getting the job done, they're showing up to work-- internally, you know, they, the feeling of depression that could go on and then they could also potentially even have suicidal thoughts, and even self-harm behaviors, but it shows up very differently. It's much more planned out.
Keith Sutton, Psy.D. (31:24):
Sure.
Alicia Smart, Psy.D. (31:25):
I've noticed. Or it tends to be even self-harm, if they do self-harm, it tends to be more ritualistic and also very planned and secretive.
Keith Sutton, Psy.D. (31:32):
Yeah.
Alicia Smart, Psy.D. (31:33):
Like you know, under controlled clients might have a lot of cuts, like very visible on their arm. Right. Where like an OC person, if they are self-harming, it might be like inner thigh, right? Be like somewhere where no one can see it and it's very hidden.
Keith Sutton, Psy.D. (31:51):
Yeah. Okay. So in OCPD, meaning obsessive compulsive personality disorder. And what is the-- and what's the conceptualization of how the person's struggling or why they're maybe kind of coping in these different ways and where you're trying to help them shift to?
Alicia Smart, Psy.D. (32:11):
Yeah, so I was talking like that biosocial model for DBT; Thomas Lynch made his own biosocial model for RO as well. And so he emphasized that the temperament for somebody who develops OC tends to be they also can be emotionally sensitive, but they also tend to be low reward sensitive. And they also tend to be a little bit more threat sensitive. So they're kind of a little bit more vigilant, maybe more cautious. And they tend to get a lot of reinforcement for internalizing distress. So they may not show their emotions. And they get really good at masking and hiding their feelings. And they get really good at performing and they, you know, maybe even unfortunately the environment kind of reinforces this perfectionistic kind of controlled way of being. And so like mistakes, they can get rigid in their thinking where they're like, mistakes can't be tolerated. Like, ‘I can't be imperfect, I must be per-’ like, you know, so they internally can be suffering with lots of guilt and shame and difficult feelings, but they're not showing it.
Keith Sutton, Psy.D. (33:24):
Yeah. Well, and I'm thinking of kind of different clients, like thinking about like, you know, one category, oftentimes a lot of men that I work with, that are just like, you know, kinda emotionally avoidant, just, you know, keep moving forward and high achieving and so on, but not necessarily speaking about their needs, or so on. Or some of my other clients, especially a lot of my clients with CPTSD, where there's more perfectionism, they’re the high achievers at work and so on, and doing everything. But at the same time, they're also feeling kind of constantly like anxious, constantly. Like, I'm gonna screw something up.
Alicia Smart, Psy.D. (34:01):
I'm gonna do something wrong
Keith Sutton, Psy.D. (34:03):
Or so on. And so I have to just like kind of be always on and always, you know, kind of in this hypervigilant state, is it, is it both of those kinds of situations or is it more like that kind of men like, kind of cut off from the emotions, just shut it all down situation? Or is it more like internally, like constantly anxious and panicking, although on the outside looking totally fine?
Alicia Smart, Psy.D. (34:26):
It can be both. I mean, I, I think this is the way, you know, when I, when I went and did the training and I learned about RO you know, I think at therapists we often do, it would be nice and easy if things like fit nice and cleanly in a box <laugh>, where it's like, okay, you're under controlled. Okay, you're over-controlled. And in reality in the therapy room, I've found that some people have both, you know, like that, that there, the, there is a reality of like, you know, Thomas Lynch calls -- like if you have an overall kind of model of being that tends to be over controlled, like you like things a certain way, you're, you're able to kind of, you're good at repressing your emotions, you're not emotionally vulnerable. Maybe you have a pretty kind of flat affect just your presentation tends to be more OC. But then you, what he referred to as emotional leakage, where occasionally it's like, push down, push down, push down, and then boop, emotions come out. That could still be an OC presentation, even though you're seeing occasional, you know, emotional outings. And I would say from my own experience with clients, there have been some clients that actually really do need some DBT to start because they're kind of at a crisis when they come in. But then after we get past the crisis, I start to see, actually, their main way of functioning in the world is to kind of be perfectionistic and rigid with themselves. And so then I'm like, okay, we need to transition to RO. And so yeah, they're, I, I went and tried to see, there's not a ton of research for that yet.
Keith Sutton, Psy.D. (36:00):
Sure.
Alicia Smart, Psy.D. (36:01):
But there are people who benefit from a little bit of both.
Keith Sutton, Psy.D. (36:04):
Definitely. Okay. Great. Yeah. And so what are the skills like, and what are the, I don't know if it's broken into the modules, a similar module kind of style as DBT?
Alicia Smart, Psy.D. (36:15):
Yeah, so it's a little bit, it's a different structure. So there are 30 lessons total. And they're not broken up into modules, although there is a mindfulness section as well, which it's somewhat similar. And I would say the main three tools that I think that could be helpful for clinicians or people listening to hear about are the idea of radical openness, which is, you know, kind of in the name. So that is about cultivating curiosity and nonjudgmentalness towards yourself and your own experiences, which include being able to be imperfect. So, you know, learning to be kind of open to the idea of different perspectives, taking feedback, you know, and then that, with this idea of self-inquiry, is also a huge one that gets practiced throughout the RO. So that could talk pretty early on in the lessons. And then if you're doing individual RO therapy, oftentimes you encourage a client to keep a self-inquiry journal as part of their process. So the self-inquiry is really about just getting very curious about, ‘okay, where did I learn this?’ Like, let's say I have a thought, you know, ‘it would be terrible if I'm, if I make a mistake.’
Keith Sutton, Psy.D. (36:63):
Sure.
Alicia Smart, Psy.D. (37:37):
‘Okay. Where did I learn that thought? Hmm. How do I know that?’ Getting curious about where do I feel -- like ‘what happened to my body when I think I did make a mistake?’ Just kind of really exploring. In this kind of open way of like, where did this belief come from and is this true? And is there any other possibilities? And so, kind of just doing this process of journaling, especially for people with more overcontrol, it just kind of helps to break up some of these beliefs that we might be coding.
Keith Sutton, Psy.D. (38:08):
And is it that, like, kind of creating cognitive flexibility? Like, I'm wondering if I'm thinking of like, sometimes when I work with a couple and one person has just got a very rigid, or I, I don't have a better word for it, it's like kind of a righteousness of like, like, ‘why aren't you doing it that way?’ Like, that's just the right way to do it. Like there's, you know, no other, like, not really kind of seeing that different people have different preferences and ways about going around the world. It just feels like, I, I don't know if that kind of fits.
Alicia Smart, Psy.D. (38:33):
Yes, a hundred percent. So it's all about creating more cognitive flexibility for, for people who are overcontrolled. That's one of the issues -- that rigidity -- and still being able to be more cognitively flexible. And then the other piece is around social signaling that is often very important to deal with the loneliness that many people who are OC feel, which is, you know, because they've gotten so good at repressing, and, you know, not expressing how they feel -- people don't really know how to connect with them. So often times, they'll hear from other people in their life, like, ‘I don't know how I feel like I don't quite know you. Or like, I don't know how to get to know you.’ Like, they're almost like, there's a little bit of a wall up.
Keith Sutton, Psy.D. (39:12):
Sure.
Alicia Smart, Psy.D. (39:13):
There’s a great metaphor that is in the RO content about a man with his hunting dogs and swords. And so, the idea here is that the man is complaining to his cousin that he can't make any friends. And he, the cousin's like, ‘okay, you just need to go to the town and like, you know, sit in the square and be open to talking to people. You know, you'll see people wanna talk to you.’ And he’s like, okay. So he goes and he sits in the square, and he got his, you know, his shield and his sword and his three hunting dogs, right? And he comes back and he reports to his cousin, ‘look, I went and I, no one talked to me.’ And it’s like, okay, but how did you show up? You showed up with a sword, a shield, and all these hunting dogs around you, right? So it's not signaling openness, it's not signaling ‘I want to connect.’ And so getting curious about, you know, our body language, our facial expressions, our tone of voice and being able to, and that's where the individual therapy can be really helpful. And actually doing RO is actually pretty fun. 'cause there's a lot of like, you know, like, let's get curious. Let's try to be silly. Let's try to be, you know, there's a lot of irreverence and humor. Try to, you know, change our social signaling to demonstrate openness and fluctuating
Keith Sutton, Psy.D. (40:31):
Yeah. Kinda loosen up,
Alicia Smart, Psy.D. (40:33):
Loosen up. Yeah. It was basically about loosening up.
Keith Sutton, Psy.D. (40:36):
Yeah, definitely. Yeah.
Alicia Smart, Psy.D. (40:37):
It's just like, DBT is for those who feel too much and act too big. <Laugh>, right?
Keith Sutton, Psy.D. (40:41):
Yeah. Yeah.
Alicia Smart, Psy.D. (40:42):
And then RO is like, like, we're trying to loosen up and actually express a little bit of what's going on inside.
Keith Sutton, Psy.D. (40:47):
Yeah. Yeah. Sometimes I think about it particularly, you know, in couples that I work with where like one couple I worked with, she talked about her husband saying there's, there's no there, there he's just like, you know, that, that she needed a more emotional connection. Part of the reason she picked him is because he was so safe and so steady, unstable, and she had grown up in a trauma situation, but now it's hard to feel that connection. And so the way I think about it sometimes it's like the person has the firearm inside of them, but sometimes there's so many walls that you can't feel the warmth. And so kind of helping the person to access that and, and be able to express it and kind of bring that out is a process.
Keith Sutton, Psy.D. (41:31):
Ok, Great. So tell me a little bit about TheraHive and you know, kind of how that works. And I know, you know, for myself, I've learned about the skills. I've read workshops, I've used different ones, but I've almost felt like, oh, it'd be great to even just like go through a DBT, you know, kind of program just to like, you know, kind of get more experience and more focus on that and such. Tell me about that, 'cause I think it has both for clients as well as like some stuff for therapists. Is that right?
Alicia Smart, Psy.D. (42:03):
It does. Yeah. So we actually, so TheraHive, as I was saying, was kind of our COVID brainchild that we released to the world and it is international, like anywhere in the world, you can take the courses and it, it's made for people who wanna learn DBT. And so we do have a track just for adults, and it is the skills, basically the skilled portion of DBT. So you're learning all four modules. We also have a teen program for teens, and now we also have a parent one where a parent can learn tools as well to support emotionally sensitive kids who might have big emotions and who are doing DBT or need DBT. And then, yeah, we went and got APA approval for a CU course for a therapist if they also wanna go through the program and learn to DBT skills.
Keith Sutton, Psy.D. (42:54):
Great. Wonderful. And how similar/different is that to what the clients are going through?
Alicia Smart, Psy.D. (43:01):
So, it's actually a lot -- I mean, some of the videos are basically the same videos, and so yeah, there's a lot of overlap. And so you'll be getting kind of the same course material as if you are participating as a, and then some of the written content is, you know, specified for how to teach, teach DBT and more specified explanation.
Keith Sutton, Psy.D. (43:18):
Yeah. Wonderful. And what are your thoughts on, like, as a therapist who's learning DBT what, what are some of the biggest challenges for folks? I know that you also do a lot of training and supervising, and yeah. And so on. You know, what, have you noticed that's, that's maybe areas that come more easily to folks /clinicians, areas that maybe are a little more difficult? Challenging.
Alicia Smart, Psy.D. (43:46):
Yeah. So I think, I mean, many people I think really resonate with the skills pretty easily. Learning the skills, being able to teach the skills, and practice skills with clients. I think doing the individual DBT work, I think can be pretty intimidating sometimes for clinicians if they don't have the right support. Because the clientele, I mean, it can be depending, I mean, not all clients who need DBT are suicidal or self-harming and, I think that’s the fear sometimes. And yes, DBT is helpful for those people. So I mean, typically, you know, I've been running a DBT center for like almost 15 years now. I would say there's a mix. You know, some people may have those things and if you, if you do have a client with suicidality and self-harm, having the consult group or having a supervisor that can support you with that, because it can, you know, it can be upsetting and stressful when you have a client who's engaging in really high-risk behaviors. And having that support is just so important, you know, to get the training on how to make sure you are not reinforcing anything. And also, you know, how to respond in a way that's gonna be effective and to take care of your own emotional distress, 'cause you know, we're human. We also get attached to our clients and have feelings about our clients. And so it's so important to get support.
Keith Sutton, Psy.D. (45:12):
Yeah. And can you talk about that, because that is an aspect of the DBT, right? Kind of the official DBT kind of approach is that there's the group, there's also the individual work, but then there's also the therapist having a consultation or team or so on to be able to process and, and that support and so on. Tell me a little bit about that.
Alicia Smart, Psy.D. (45:34):
Like, yeah. Yeah. So that is like, if we go back to that idea of comprehensive DBT, those are the four components. They're the group, the individual therapy, the consult team for the therapist, and then also phone coaching, right? So being able to call your therapist to get coaching in between sessions to use the skills. So like you're learning the skills in a group, but then like, are you applying them in your life, right?. And so before you self-harm, calling your therapist, getting coaching, being able to use a skill in the moment is so like, important for skill generalization. But yeah, the, the, the consult team really is about DBT for the therapist. So it is, you know, for us to also practice the skills on ourselves and support each other, but also to allow us and make sure that we're being adherent to the treatment, right? Because it's easy to drift.
Keith Sutton, Psy.D. (46:28):
Yeah.
Alicia Smart, Psy.D. (46:29):
And in some ways, you know, I had a supervisor a long time ago when I was first learning DBT say that like, sometimes you can feel like clients are actually reinforcing you for doing bad therapy or like not holding them to the DBT, right? Because they don't wanna talk about the thing that, you know, they don't wanna talk about their self-harm behavior. They might reinforce you to like, ‘let's just skip that part of your diary card and talk about the thing of the day.’ But that's not gonna help them learn a different way of coping if we don't address the thing. So it's almost like, you know, going where, you know, angels fear to tread like this idea of like, we also have to go opposite that urge to just make it better or make them feel good. And so that's where the consult team is so important, you know, to be able to get that feedback and help to make sure that you're holding yourself accountable and the client accountable to the treatment that's really gonna get them better.
Keith Sutton, Psy.D. (47:23):
Yeah. Well, yeah. And I think for therapists, right, that feels very gratifying to be like the person the person wants to talk to and the listener and the like, you know. Feeling that connection and that like, we're the only ones that can talk about this stuff. But yeah, it's, it's oftentimes sometimes unknowingly colluding with avoidance. Right?
Alicia Smart, Psy.D. (47:43):
Right. And that's why there, again, there's a dialectic within the therapy itself because like obviously, you know, we wanna validate our clients and I think there's the requirement of a certain amount of validation for the client to feel like, ‘oh, you get me, you understand me.’
Keith Sutton, Psy.D. (47:56):
Oh yeah, definitely.
Alicia Smart, Psy.D. (47:57):
In order for you to then even offer a chain strategy. And so that, yeah, it's kind of like that dance again where we're like validating and like --
Keith Sutton, Psy.D. (48:08):
Definitely. And can you speak to the coaching aspect? 'cause I think that's something that I've I know when I originally heard about that or other people are like, Ooh, I don't know if I want to take phone calls all the time. You know, and from clients or, you know, I think sometimes, it may even be at night or, you know, like weekends or, or so on. Tell me a little bit about how that works and how do you manage that? And, and, but I also know it's, it's also a big, big part of it.
Alicia Smart, Psy.D. (48:34):
Yeah. So I, I, it's a great question, Keith. 'Cause I think that going back to your question of like, you know, what might make it challenging for some therapists to go into DBT is this idea of phone coaching and being available. And I will say, you know, one of, again, because of the model and it being flexible, you know, part of the consultation agreement is that we observe our own limits as a therapist. And so, you know, our center has interpreted that and allowed it so that every therapist gets to set their own hours for phone coaching. So like, my hours tend to be like 8:00 AM to 8:00 PM, right? So I'm available-- and I am available on weekends, but after eight o'clock, I'm not available. Right? And so, and if I know I have an event or I know, like, I'm gonna be away; another part of being on a team is that I can get phone coverage, right? So if I know that, like, let's say I wanna go to Tahoe or I wanna go somewhere for a weekend and I, I'm not gonna be available, then someone else can cover for me.
Keith Sutton, Psy.D. (49:34):
Yeah, great. And how often do clients tend to use the phone coaching? Is that something that the client's calling a couple times a day, seven days a week, or it's like once a week? How does that help?
Alicia Smart, Psy.D. (49:48):
Yeah, so I mean, it varies for clients. Honestly. I will say the majority of clients don't use it as much as they should. I mean, I often times have to talk to clients about, ‘Hey, I'm available to you. What's getting in the way of calling me?’ 'cause clients don't wanna bother you, right? They don't wanna, you know, they're concerned that you might reject them, especially if they have BPD, they might actually be fearful that they might be too much because they've been told they're too much by other people. So, sometimes I actually have to do the opposite, like encouraging more phone calls. Now, occasionally there might be one client who tends to overuse it and if they do overuse it, then that's become the therapy-interfering behavior that we can talk about and shape, right? When people are using it appropriately, maybe once a week, I mean it in the beginning it might be a little bit more in terms of like, as they were learning the skill, but the idea is that they become more independent. And part of the phone coaching is that they do need to attempt a skill before they call you. Not like they're just gonna, you know, so sometimes they'll be like, ‘okay, I'm having this issue, I'm thinking about calling, let me try the skill, and oh, it worked. I don't need to call my therapist.’ So, it's a lot less than I think people think.
Keith Sutton, Psy.D. (51:01):
And I think there's also something too around like, how you engage in the phone coaching if they've already, say, engaged in the unhealthy coping?
Alicia Smart, Psy.D. (51:11):
That's right. Yeah. So there's a 24 hour rule, and I'm glad you brought that up. And it does work as a contingency and it's actually incredibly effective. Because clients don't wanna lose, even if they're not using the phone coaching, they often don't wanna lose the potential to have access to you. And so, you know, I've had clients who've actually told me in therapy, like, ‘I didn't self-harm because I didn't want the 24 hour rule to go into effect.’
Keith Sutton, Psy.D. (51:37):
So if the client self-harms, then they don't have the phone coaching available for 24 hours.
Alicia Smart, Psy.D. (51:43):
Yes. Yeah.
Keith Sutton, Psy.D. (51:44):
Does that apply to other behaviors such as, I guess the, the explosiveness, or alcohol, or things like that? Or is it just…
Alicia Smart, Psy.D. (51:51):
It's just for self-harm. Yeah. Just for self-harm and the idea that we want to encourage calling and reaching out before engaging in that behavior. And so once you've done it, there's nothing to really coach. 'cause you've already done the -- you've already solved the problem in an ineffective way.
Keith Sutton, Psy.D. (52:06):
Yeah. That usually kind of, yeah, helps manage the overwhelm or whatever kind of emotions that are going on.
Alicia Smart, Psy.D. (52:13):
Exactly.
Keith Sutton, Psy.D. (52:14):
Yeah. Well, this is great. This is so interesting to hear about and learn. And I know you've been really steeped in DBT for, for so long and also the Radically Open DBT and really kind of bringing that into your work and into the work that you do and the training that you do. And it's so great to hear about TheraHive and really having that as something that makes all of this accessible to both clients as well as to therapists. And is that through a website, an app? Is that-- um, how do folks kind of find it, or sign up, or get going?
Alicia Smart, Psy.D. (52:49):
Yeah, so therahive.com. It is a website, they can sign up and find out more information there, and it's an online learning platform. So yeah, they can check it out.
Keith Sutton, Psy.D. (53:03):
Okay, great. Well, I'll link it in the information that we put up on the website. Well, thanks so much. I really appreciate you taking the time. This was really great. Thanks a lot.
Alicia Smart, Psy.D. (53:13):
Thank you, Keith.
Keith Sutton, Psy.D. (53:14):
Take care, bye-bye.
Alicia Smart, Psy.D. (53:16):
Bye.
Keith Sutton, Psy.D. (53:17):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in-person in the Bay Area, or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC’s website at sfbacc.org. BACC is a 501(c)(3) nonprofit so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Keith Sutton, Psy.D., a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. (02:19):
Today, I'll be speaking with Alicia Smart, Psy.D., who is a licensed clinical psychologist in California with over 20 years of clinical experience providing evidence-based mental health care to children, adolescents, adults, and families. She began seeing clients during graduate training and has worked across community mental health, medical, and private practice settings throughout her career. Alicia earned her BA in Psychology and Chemistry from New York University and her doctorate of clinical psychology from the California Institute of Integral Studies. She is a DBT Linehan-certified clinician and has extensive experience treating mood and personality disorders, trauma, anxiety, grief, ADHD, autism spectrum presentations, and chronic emotional dysregulation. Her work frequently integrates DBT into suicide risk management, neurodivergent affirming care, and complex relational systems. She's the founder and clinical director of Guideposts DBT in Cort Madera, California, where she oversees a team of therapists providing comprehensive dialectical behavioral therapy and evidence-based care. In addition to clinical leadership, Alicia provides training, supervision, and consultation to clinicians seeking advanced education in DBT and related approaches. Alicia is also the co-founder of the Hive and Innovative online DBT Skills and Learning platform designed to make high-quality DBT education more accessible to individuals and clinicians worldwide. Let's listen to the interview.
Keith Sutton, Psy.D. (03:45):
Well, hi Alicia. Welcome.
Alicia Smart, Psy.D. (03:48):
Thank you, Keith. It's great to talk to you! Looking forward to getting into some interesting things around RO-DBT and DBT with you.
Keith Sutton, Psy.D. (03:56):
Yeah, definitely. Well, and I know we had talked about the group practice you were taking over, Marin DBT, some years ago, and so we connected on that and we've been in touch and, and I've consulted with you and I've done some trainings for your organization. And so, I really was glad to have you on the program today because you do a lot of work with DBT. And then also the RO-DBT, which I wanna learn more about. But first, I always like to find out about how people got to doing what they're doing -- the kind of evolution of your thinking.
Alicia Smart, Psy.D. (04:32):
Wow, okay. I have to go back to probably pre-doc. When I first got exposed to DBT during my time at Marin General -- so part of the rotation there was to run a DBT group, and that was the first time I got exposed to DBT and I truly fell in love with it because it was so practical. And I love the idea of giving people real tools that they could take away and would make a difference, and it was very exciting to see people actually use some skills and report back, like, wow, I did the thing and it helped my behavior and it helped my relationship and I'm feeling better. And so then after that I did some training with B Tech with Marsha Linehan and other people at B Tech and learned about DBT. And then I made that my specialty, really.
Keith Sutton, Psy.D. (05:22):
Great. Wonderful. And so tell me a little bit about DBT and, you know, I've done some training in DBT, but for folks that maybe aren't as familiar, I'm sure everybody's heard of it, but yeah. Can you talk a little bit about what DBT is?
Alicia Smart, Psy.D. (05:38):
Yeah. So I can actually talk about it both from what kind of clients tend to seek out DBT, but also the theoretical model. So DBT has a biosocial model, and so for a lot of clients who come into DBT, they would describe themselves as emotionally sensitive. You know, they feel emotions intently, they have a slower return to baseline, right? And they just sometimes even describe feeling like they have no, like, no skin, like things just like hurt more. And when you combine that with an invalidating environment, or it may be not even that invalidating for most people, but for somebody who's sensitive it is, they wind up basically not trusting their own emotion, having big emotion. Sometimes the environment inadvertently will actually reinforce big emotion. So, unless they're having a crisis, that's when they finally get heard. Because there's a lot of, you know, ‘oh, you're being dramatic or it's not that big of a deal.’ And that can cause more dysregulation. And so for clients who would describe themselves as, you know, emotionally sensitive, impulsive, reactive, big emotions, maybe struggle with substance use, maybe struggle with binge eating, you know, have a hard time not feeling like, you know, their emotions are controlling them -- that they don't have control over their emotions. I think those are the people who most benefit from DBT.
Keith Sutton, Psy.D. (07:06):
Yeah. When I think of DBT, I think about it as helping somebody going from being reactive to more responsive.
Alicia Smart, Psy.D. (07:12):
Yes, yes. Learning that pause, right? Learning the ability to pause before the reaction. And that's why mindfulness is such an important part of DBT. It's really learning how to put the brakes on and also bring down the intensity so that the, you know, distress tolerance part of DBT, which is like, okay, your emotion is really high -- let’s bring down the intensity so you can actually experience them. So, that's the dialectic in DBT, is that we actually want to be able to not just control our emotions, but also feel them.
Keith Sutton, Psy.D. (07:41):
Yeah, definitely. Yeah. Rather than being emotionally avoidant or like suppressing them or letting them just kind of take the wheel.
Alicia Smart, Psy.D. (07:48):
Exactly.
Keith Sutton, Psy.D. (07:49):
Yeah. Yeah. And Marsha Linehan, right, first developed it and did the research on working with clients that were diagnosed borderline personality disorder, although it's been extended to lots of different situations for folks, again, like you're saying that have that common theme of the emotional sensitivity or the emotional reactivity.
Alicia Smart, Psy.D. (08:10):
Yeah. Marsha's story about forming DBT is actually really interesting, I don't know if you know it. She describes how she really wanted to work with the suicidal people who were suicidal in the hospital. Later on, she wrote a memoir about building a life worth living -- her book is fantastic. And she was one of those people actually in the hospital, and that didn't come out until much later in her career, but she really was drawn to this population that was struggling with suicidality, and she had been trained in CBT. So, she was actually trying to apply CBT to this population and was finding that it wasn't working. They felt, in a way, very misunderstood by the CBT. They didn't-- they felt invalidated by the CBT approach. And so, she kind of added mindfulness -- the acceptance strategies, to CBT. So DBT has a lot of CBT in it. It just also has a lot of acceptance strategies around mindfulness and radical acceptance and zen, which she --
Keith Sutton, Psy.D. (09:19):
Yeah. So I think, third wave CBT is what they talked about?
Alicia Smart, Psy.D. (09:23):
Yeah. Yeah.
Keith Sutton, Psy.D. (09:24):
That's great. And so can you talk a little bit about -- I know that there's the DBT groups and they’re broken down into the four different kinds of skills: can you talk a little bit about the skills group versus the therapy that's happening?
Alicia Smart, Psy.D. (09:46):
Yeah, Great. So in order to be considered doing comprehensive DBT, you need both components. So I think there are many therapists who might say they're doing DBT, and they might be doing more like DBT-informed work, which it, you know, can, for many people, be really helpful. I would say as a DBT practitioner, that for those that have suicidality and self harm in the mix, comprehensive DBT is considered the most evidence-based. And if you have high dysregulation, they're probably going to make more progress if they have both on board. The skills group is where you learn the skills. So it's usually a two hour to an hour and a half format. You're doing mindfulness to begin, and then you have home practice every week where you're practicing a skill, so you're learning a new skill each week. And then you're practicing for that week, and then you're reporting back to the group and hearing how other people are using the skills. So, there's a sense of accountability. And there's a sense of being able to learn from other people, like, ‘oh, how this is just the kind of situation where you use the skill and this is how it works.’ So it's really a great way to learn the tools.
Keith Sutton, Psy.D. (10:56):
Yeah. And it's a different kind of group than maybe a process group, is that right?
Alicia Smart, Psy.D. (11:02):
Yeah, it's considered a psychoeducation group instead of a process group. And actually, one of the things that during Covid, when we all moved online and we were no longer doing in-person -- I'd actually started a psychoeducation company with my husband called TheraHive, where we do offer just DBT skills alone, not comprehensive, but for those who maybe have a therapist but wanna learn skills, they can still do that. So ideally if you can have both, that is most effective. And for financial reasons, I mean, therapy can be expensive. Having this other option of being able to learn the tools online can make it more affordable.
Keith Sutton, Psy.D. (11:47):
Oh, great. And so there's the -- I think there's the four areas, right? There's the mindfulness, the distress tolerance, affect regulation, and the interpersonal skills. Are those kind of the four modules or what are they called? In the DBT?
Alicia Smart, Psy.D. (12:03):
Yeah. They're called modules, that's right, Keith. So we do have mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. And then when we teach families there's actually a fifth module that we kind of add in called ‘Walking the Middle Path.’ So in the regular adult curriculum, it is also included, but we include it in the interpersonal section. But for families, we spend a whole section just on walking the middle path, which is all about holding dialectics, being able to validate -- which is so important in relationships and family dynamics -- and then reinforcement, which are really important for parents, especially for adolescents with big emotions -- to be able to learn how their behaviors may be actually intermittently reinforcing things in their teen that they don't actually want.
Keith Sutton, Psy.D. (12:54):
Right. Unknowingly reinforcing. Yeah, Okay, Great. So that was reinforcement, that was validation, and the dialectics.
Alicia Smart, Psy.D. (13:05):
Yeah. That's correct.
Keith Sutton, Psy.D. (13:06):
Great. And so I learned -- I did some training in DBT a long time ago, so just to kind of check out my understanding -- I've thought about it as the mindfulness is, yeah, creating that space for that slowing things down. You know, your typical mindfulness activities to less reactivity. The distress tolerance is something to do in the moment, rather, kind of like a harm reduction strategy or something to that effect, like holding ice in one's hand rather than cutting oneself or so on. Or distraction or so on
Alicia Smart, Psy.D. (13:47):
Or self-soothe.
Keith Sutton, Psy.D. (13:48):
Yeah. And then the affect regulation, it seemed like it was kind of the things you do beforehand, like getting good sleep, exercise, like all those things to kind of keep your resources up as much as they can be. And then of course, the interpersonal skills about being able to be open and authentic and assertive in relationships. Is that kinda how that plays out?
Alicia Smart, Psy.D. (14:10):
Yeah. I like to explain it as looking at an emotional temperature when I talk to clients about it in terms of where the skills fit in. So if you think about the baseline of zero, we're totally calm, and then a hundred, I'm losing my mind, right? I'm like, motion during control. The distress tolerance skills are the ones that we're looking at using when we're at like 75 or above, maybe 60, depending on where your threshold is -- where you feel like you're no longer in control or your emotions are overwhelming. Your distress tolerance does not solve problems. Like, distress tolerance is just about getting through the crisis without making it worse. And so it really is just about reducing the intensity. Now, as I say that though, there is a section in distress tolerance about accepting reality, which is not just about surviving the crisis, but actually being with the radical acceptance that’s put into the distress tolerance section. And for many people though, I would say the crisis survival skills, like you said, the distract the self, the holding ice, (which is called a tip skill), that's just reducing intensity. But then, ideally, we're also trying to be able to accept reality and be with what is, which then we get into our emotion regulation of mindfulness to our current emotion. Can we just be with, and allow emotion to come and go?
Keith Sutton, Psy.D. (15:31):
Yeah. Yeah. That's great. Yeah. I always, you know, I did training and exposure with response, prevention (ERP) for OCD, and exposure work was really helpful. And then learning about acceptance, commitment therapy and, you know, kind of the role of emotional avoidance and being willing to go towards discomfort rather than avoiding. And I've always had a hard time kind of trying to match that up with coping such as distraction or so on. Like when do you encourage, you know, the person's dysregulated, so you're encouraging deep breathing distraction or so on, but when does that sometimes become avoidance of the discomfort and not allowing the person to kind of ride the wave and gain the confidence that I can feel strong emotions and make it through? Because I think a lot of therapists that aren't as familiar with this kind of exposure work and sometimes unknowingly reinforce avoidance by teaching lots of skills to manage, unknowingly or kind of giving the mist, we have to get rid of anxiety or these bad feelings or so on, rather than being able to actually sit with them and embrace them and lean into that and build that muscle to experience the uncomfortable emotions. How do you reconcile that?
Alicia Smart, Psy.D. (16:42):
Well, I mean, this is where dialectics come in. I mean, it is a dialectic. I mean, this is true. I feel that that is why the model talks about dialectics so much, is that we are trying to constantly do both ends, and we are doing a dance on that. So, going back to the temperature, I like to use the thermometer as a way for us to figure it out. If we're at 85 and above, first of all, we're trying to build the window of tolerance. So maybe your tolerance is, once you're at 50, you can't tolerate anything. But let's see if we can build that tolerance to 65. At the same time, if we're at 80 and you're gonna self harm, then yes, we're gonna use a skill to bring down the intensity. But ultimately the goal is to be able to tolerate the feelings and not avoid them, right? So we're constantly dancing in that area. And I do tell clients, you know, when they're like, they're checking off their diary card and they're using self-soothe and distract all the time, I'm like, ‘okay, like, let's look at that. Could that look like, I mean, great, you're using skill, but are we avoiding? Are we actually using the skills as a way to not deal with problems and emotion?’
Keith Sutton, Psy.D. (17:45):
Sure. Yeah. Yeah. And I've heard of it too as sometimes using some of those coping skills to stay with the emotion and kind of be with it rather than get rid of the emotion. Exactly.
Alicia Smart, Psy.D. (17:56):
Like the titrating. Right. Because actually DBT is exposure work; it's exposure to emotion and being with feelings.
Keith Sutton, Psy.D. (18:04):
Oh, great. You were kind of saying that distress tolerance is more like 75 and above. What are your thoughts on what's below 75?
Alicia Smart, Psy.D. (18:20):
I think that, I think that's where the emotion regulation comes in. So if we're thinking about mindfulness to emotion, riding the wave, feeling our feelings, right? But also doing things to reduce vulnerability in the first place. So you had mentioned sleep, which is a huge one, Keith. I mean, so important for so many people and very dysregulating when we don't get enough of it. And so sleeping, eating, exercise, like all of those things, taking meds as prescribed, not abusing substances. So those are part of the, and then checking the facts. I mean, there's other emotion regulation skills, like looking for cognitive distortion. So checking the facts really does come out of CBT, and by checking the facts, we're looking for a cognitive distortion. Are we being black and white? Are we minimizing? Are we generalizing? Are we being catastrophic in our thinking? Right? Sure. So those tools can get added in there. And then when we realize, ‘oh, sometimes our emotions are not based on what's actually happening, but our interpretation of what's happening.’
Keith Sutton, Psy.D. (19:19):
Yeah. Great. So yeah, so kind of that those cognitive skills are still in there, but like, again, there's a whole other kind of array of tools to be able to be used.
Alicia Smart, Psy.D. (19:29):
Right.
Keith Sutton, Psy.D. (19:30):
And in the individual therapy you know, when I did my training many years ago, like 15 years ago, one of the things that they had talked about was that sometimes, because many clients sometimes are coming in with a borderline personality disorder, and sometimes there's a lot of focus on the, the recent drama that's going on, that they, when there has been say a self-harm or, or relapse of some sort, that oftentimes kind of the focus is to address that and do some chain analysis -- looking at what led to that before kind of getting into the drama of the week almost as a reinforcement or even a lack of a reinforcement of being able to get into maybe the news of the week. And instead, first dealing with, and thus decreasing some of the behaviors, even just through that kind of process within the therapy. I don't know how much that is correct or structured…
Alicia Smart, Psy.D. (20:30):
Yeah. So you had asked me, and it kind of goes back to that other question of like the, in some ways the difference between the group and the individual therapy. So in DBT individual therapy, especially stage one, so there's stages of DBT. So stage one is all about, you know, reducing crisis behavior. Like if there's suicidality, making sure of we're reducing suicidal crises. So we often are pretty structured during that first year or first six months of treatment. Depending on what the client has going on, like if they're PTSD, we might move after we get some stabilization into exposure work or, you know, prolonged exposure work as part of the treatment in stage two. But typically we have a diary card. The client and I will talk about, okay, what are, what are the targets, what are the quality of life interfering behaviors that you're engaging in, right? So maybe I am, you know, I'm explosive with my anger. I throw things to my partner when I'm, right? I, I have, I struggle with my eating. I wind up overeating and then I go into a shame cycle. I'm self-harming, like all these things that the client might say they're doing. And so those become targets that we're looking at on the diary card. And so once we're, every week we use the diary card actually to set the structure for the session. So first off, life threatening behavior; if there's any suicidality on that diary card, we're gonna address that first. And then we would also address any self harm.
Alicia Smart, Psy.D. (22:01):
Next -- we would actually address therapy interfering behavior next. So let's say the client had been inappropriately using phone coaching. Instead of calling the therapist and getting phone coaching help for skills, they've been calling and venting. Or you're, when I'm offering the skills of the client, they're rejecting the skill and saying, ‘no, that won't work. No, that won't work. No, that won't work.’ So then we're gonna talk about that in the therapy and how that's impacting our relationship and our ability to work together. And so we're gonna resolve that. So I also encourage clients if there's anything that I'm doing that’s making it hard for them to show up, or making it difficult for them to engage, then we're gonna talk about that too. Because if we don't have a good therapeutic alliance, then we really can't do much work. Right?
Keith Sutton, Psy.D. (22:51):
Yeah, we can't go anywhere from there.
Alicia Smart, Psy.D. (22:52):
Exactly. And then the last part is quality of life interfering. So we have life threatening, therapy interfering, and then quality of life interfering, that we address by looking at that diary card. And that kind of sets the stage for the session. So, in terms of like the drama of the day or the thing that might be in the quality of life, but that might be the last thing we address, depending on what else offered on the diary card.
Keith Sutton, Psy.D. (23:18):
Yeah, definitely. So kind of having that process of kind of the priorities of what's gonna get focused on in the work.
Alicia Smart, Psy.D. (23:26):
Yeah.
Keith Sutton, Psy.D. (23:28):
And then can you talk a bit about the concept around dialectics and, and what that kind of means in, in DBT? And, you know, I know there's a huge overlap with complex PTSD, along with borderline personality disorder, and oftentimes with emotional reactivity, substance abuse, all these kinds of pieces. Growing up in that invalidating environment oftentimes can lead to some of that structural dissociation kind of black and white thinking. Can you talk a little bit about dialectics?
Alicia Smart, Psy.D. (24:01):
Yeah. So I think, I mean, this is really the premise of DBT, it's one of the things that really allowed the treatment to be flexible too. It's one thing that I really appreciate because the idea of dialectic is that we're holding two things to be true at the same time, and that there's no ultimate truth, that truth is evolving over time. So it allows us to be curious and flexible. It reduces rigidity, which I think for many clients, especially when you think about like, even, I mean, I consider myself a very regulated person. However, when emotions do get high, it is easy to see how when emotions are very activated, we become narrower in our mental flexibility. I mean, I'm sure anybody listening can acknowledge that in themselves when you have these thoughts of like, ‘oh, you never are, you always,’ that's a black and white thought, right? And so anytime you catch yourself or you notice your client saying ‘always’ or ‘never,’ right? That is an indication that up black and white thinking has shown up, right? And so the dialectics is basically a way to hold that, okay, there could be more than one way of looking at this problem and more than one way of viewing things. And that there is no ultimate ‘okay, this is the only truth,’ right? And so we become more open.
Keith Sutton, Psy.D. (25:22):
Yeah. Yeah. And, can you give an example of working with the dialectics with a client or what that looks like in practice?
Alicia Smart, Psy.D. (25:32):
Yeah. So I think this, I mean, it, there're internal dialectics that we need to hold, but then there's dialectics and relationships. And so I'll, I'll bring up one recently with a couple where, you know, there was this idea that, and we actually did a video of this, this example I'm gonna give on our YouTube channel for TheraHive, if anybody wants to learn dialectics in practice. But basically, you know, a man, he'd, he asked his wife to clean up after dinner, right? And then she doesn't do it, right? And then the feeling of like, she doesn't care about me, like indicates like in his mind, this is just a sign she doesn't care about me. Like I asked her, she didn't do it. And then getting very, very angry, right? So if I'm holding dialectics, we would challenge or kind of get curious about that thought. Is there any other possible interpretation besides she doesn't care about you? That she didn't do the dishes? Yeah. Okay. Well, she did say she was tired. You know, like, and then kind of exploring like maybe there's some other reason, maybe it's not this one thing I'm holding onto, this is the reason, as evidence. And so can I hold both truths? Like it upsets me, and I'm hurt that she didn't do what I asked her to do, and it might be totally possible that she's just tired and forgot.
Keith Sutton, Psy.D. (26:56):
Yeah. Yeah. Right.
Alicia Smart, Psy.D. (26:58):
Both things could be true
Keith Sutton, Psy.D. (27:00):
Kind of holding, at the same time, both feelings: feeling uncared for, and, at the same time, maybe it is not necessarily being malicious.
Alicia Smart, Psy.D. (27:08):
Right, or intentional, even.
Keith Sutton, Psy.D. (27:10):
Yeah. Or, or so on. And kind of holding at the same time. makes me think about, I was interviewing somebody around cognitive processing therapy and I forget what they called it, the trust star or something like that, of where you're looking at different, rather than, I can't trust this person, looking at different aspects of where you can trust more, or less, or so on and, and looking at the whole picture rather than--
Alicia Smart, Psy.D. (27:31):
To one incident. Yeah,
Keith Sutton, Psy.D. (27:32):
Exactly. Definitely. As all or none. Okay. Great. And particularly to that, that, so there's the DBT and then tell me about the radically open DBT and, and, I've heard a little bit about that and we've talked about it, but I haven't done training in that specifically. I'd love to hear more and understand the differences.
Alicia Smart, Psy.D. (27:55):
Yeah. So RO-DBT, it's pretty-- it's much newer. I mean DBT had been around in the eighties. You know, even I think Marshall Linehan started actually developing in the late seventies and had kind of published her book, I think in, in the early nineties. But I think she was kind of developing it and thinking about it for a while. But RO-DBT, I think, Thomas Lynch published his book probably in 2017 or 2016, maybe 2018, anyway, but more recently. And I went and did a training with him. And I'll admit when I went to the training, I didn't actually know what I was signing up for. I was just like, ‘oh, DBT, like another thing of DBT.’ And so I, loving all things DBT, I wanted to get trained in it. And so it is an entirely different treatment. It is not the same treatment.
Alicia Smart, Psy.D. (28:45):
It has a whole set of new skills that are not related to the DBT skills. I will say they overlap in the sense that they're both behavioral therapy. And they're dialectical in nature. And so that is why the DBT is still included in RO-DBT because it has that background. And Thomas Lynch trained with Marsha and is very well versed in DBT. So he came from a DBT background. Or he developed RO-DBT, but RO-DBT, if you think about what I was saying before, the clients who benefit from DBT are kind of under controlled in their emotions. Yeah. RO-DBT at the other end of the spectrum, is for the overcontrolled population. So this is designed for people who tend to be more perfectionistic, emotionally restrained, and they actually are really good <laugh> at controlling their emotions. But they have a hard time being vulnerable and open and expressing emotion. And so, they are also struggling, but they're struggling in a very quiet way. Typically, they might because they're not necessarily being big and dramatic with their emotional suffering, it's more internal and they may feel really lonely.
Keith Sutton, Psy.D. (29:58):
Yeah. Say more about that. Like what and how are these folks kind of coming in? Are they coming in because they're feeling depressed or they're feeling disconnected? I almost think about this as the person that's being the good soldier, whatever, just kind of pushing it down and moving forward, which sometimes aren't. Maybe the person that's like, ‘Hey, I need to go to therapy.’ Oftentimes, it is coming up in a different way.
Alicia Smart, Psy.D. (30:24):
Yeah. So, I mean, there's a couple of different ways they could be coming in. I mean, some people with an OC presentation might resort to more extreme OC behaviors like OCPD. In which case it would be like more visible to other people, or anorexia, I think. Another obvious one where they do tend to be more overcontrolled and they do wind up in therapy, not because necessarily they wanna be, but because they're underweight and they're referred to therapy. But yes, chronic depression is also a big one. Because if it does go on and we feel more isolated and disconnected, it does create a feeling of being depressed. So even though, yes, they're, you know, meeting all their markers, they're getting the job done, they're showing up to work-- internally, you know, they, the feeling of depression that could go on and then they could also potentially even have suicidal thoughts, and even self-harm behaviors, but it shows up very differently. It's much more planned out.
Keith Sutton, Psy.D. (31:24):
Sure.
Alicia Smart, Psy.D. (31:25):
I've noticed. Or it tends to be even self-harm, if they do self-harm, it tends to be more ritualistic and also very planned and secretive.
Keith Sutton, Psy.D. (31:32):
Yeah.
Alicia Smart, Psy.D. (31:33):
Like you know, under controlled clients might have a lot of cuts, like very visible on their arm. Right. Where like an OC person, if they are self-harming, it might be like inner thigh, right? Be like somewhere where no one can see it and it's very hidden.
Keith Sutton, Psy.D. (31:51):
Yeah. Okay. So in OCPD, meaning obsessive compulsive personality disorder. And what is the-- and what's the conceptualization of how the person's struggling or why they're maybe kind of coping in these different ways and where you're trying to help them shift to?
Alicia Smart, Psy.D. (32:11):
Yeah, so I was talking like that biosocial model for DBT; Thomas Lynch made his own biosocial model for RO as well. And so he emphasized that the temperament for somebody who develops OC tends to be they also can be emotionally sensitive, but they also tend to be low reward sensitive. And they also tend to be a little bit more threat sensitive. So they're kind of a little bit more vigilant, maybe more cautious. And they tend to get a lot of reinforcement for internalizing distress. So they may not show their emotions. And they get really good at masking and hiding their feelings. And they get really good at performing and they, you know, maybe even unfortunately the environment kind of reinforces this perfectionistic kind of controlled way of being. And so like mistakes, they can get rigid in their thinking where they're like, mistakes can't be tolerated. Like, ‘I can't be imperfect, I must be per-’ like, you know, so they internally can be suffering with lots of guilt and shame and difficult feelings, but they're not showing it.
Keith Sutton, Psy.D. (33:24):
Yeah. Well, and I'm thinking of kind of different clients, like thinking about like, you know, one category, oftentimes a lot of men that I work with, that are just like, you know, kinda emotionally avoidant, just, you know, keep moving forward and high achieving and so on, but not necessarily speaking about their needs, or so on. Or some of my other clients, especially a lot of my clients with CPTSD, where there's more perfectionism, they’re the high achievers at work and so on, and doing everything. But at the same time, they're also feeling kind of constantly like anxious, constantly. Like, I'm gonna screw something up.
Alicia Smart, Psy.D. (34:01):
I'm gonna do something wrong
Keith Sutton, Psy.D. (34:03):
Or so on. And so I have to just like kind of be always on and always, you know, kind of in this hypervigilant state, is it, is it both of those kinds of situations or is it more like that kind of men like, kind of cut off from the emotions, just shut it all down situation? Or is it more like internally, like constantly anxious and panicking, although on the outside looking totally fine?
Alicia Smart, Psy.D. (34:26):
It can be both. I mean, I, I think this is the way, you know, when I, when I went and did the training and I learned about RO you know, I think at therapists we often do, it would be nice and easy if things like fit nice and cleanly in a box <laugh>, where it's like, okay, you're under controlled. Okay, you're over-controlled. And in reality in the therapy room, I've found that some people have both, you know, like that, that there, the, there is a reality of like, you know, Thomas Lynch calls -- like if you have an overall kind of model of being that tends to be over controlled, like you like things a certain way, you're, you're able to kind of, you're good at repressing your emotions, you're not emotionally vulnerable. Maybe you have a pretty kind of flat affect just your presentation tends to be more OC. But then you, what he referred to as emotional leakage, where occasionally it's like, push down, push down, push down, and then boop, emotions come out. That could still be an OC presentation, even though you're seeing occasional, you know, emotional outings. And I would say from my own experience with clients, there have been some clients that actually really do need some DBT to start because they're kind of at a crisis when they come in. But then after we get past the crisis, I start to see, actually, their main way of functioning in the world is to kind of be perfectionistic and rigid with themselves. And so then I'm like, okay, we need to transition to RO. And so yeah, they're, I, I went and tried to see, there's not a ton of research for that yet.
Keith Sutton, Psy.D. (36:00):
Sure.
Alicia Smart, Psy.D. (36:01):
But there are people who benefit from a little bit of both.
Keith Sutton, Psy.D. (36:04):
Definitely. Okay. Great. Yeah. And so what are the skills like, and what are the, I don't know if it's broken into the modules, a similar module kind of style as DBT?
Alicia Smart, Psy.D. (36:15):
Yeah, so it's a little bit, it's a different structure. So there are 30 lessons total. And they're not broken up into modules, although there is a mindfulness section as well, which it's somewhat similar. And I would say the main three tools that I think that could be helpful for clinicians or people listening to hear about are the idea of radical openness, which is, you know, kind of in the name. So that is about cultivating curiosity and nonjudgmentalness towards yourself and your own experiences, which include being able to be imperfect. So, you know, learning to be kind of open to the idea of different perspectives, taking feedback, you know, and then that, with this idea of self-inquiry, is also a huge one that gets practiced throughout the RO. So that could talk pretty early on in the lessons. And then if you're doing individual RO therapy, oftentimes you encourage a client to keep a self-inquiry journal as part of their process. So the self-inquiry is really about just getting very curious about, ‘okay, where did I learn this?’ Like, let's say I have a thought, you know, ‘it would be terrible if I'm, if I make a mistake.’
Keith Sutton, Psy.D. (36:63):
Sure.
Alicia Smart, Psy.D. (37:37):
‘Okay. Where did I learn that thought? Hmm. How do I know that?’ Getting curious about where do I feel -- like ‘what happened to my body when I think I did make a mistake?’ Just kind of really exploring. In this kind of open way of like, where did this belief come from and is this true? And is there any other possibilities? And so, kind of just doing this process of journaling, especially for people with more overcontrol, it just kind of helps to break up some of these beliefs that we might be coding.
Keith Sutton, Psy.D. (38:08):
And is it that, like, kind of creating cognitive flexibility? Like, I'm wondering if I'm thinking of like, sometimes when I work with a couple and one person has just got a very rigid, or I, I don't have a better word for it, it's like kind of a righteousness of like, like, ‘why aren't you doing it that way?’ Like, that's just the right way to do it. Like there's, you know, no other, like, not really kind of seeing that different people have different preferences and ways about going around the world. It just feels like, I, I don't know if that kind of fits.
Alicia Smart, Psy.D. (38:33):
Yes, a hundred percent. So it's all about creating more cognitive flexibility for, for people who are overcontrolled. That's one of the issues -- that rigidity -- and still being able to be more cognitively flexible. And then the other piece is around social signaling that is often very important to deal with the loneliness that many people who are OC feel, which is, you know, because they've gotten so good at repressing, and, you know, not expressing how they feel -- people don't really know how to connect with them. So often times, they'll hear from other people in their life, like, ‘I don't know how I feel like I don't quite know you. Or like, I don't know how to get to know you.’ Like, they're almost like, there's a little bit of a wall up.
Keith Sutton, Psy.D. (39:12):
Sure.
Alicia Smart, Psy.D. (39:13):
There’s a great metaphor that is in the RO content about a man with his hunting dogs and swords. And so, the idea here is that the man is complaining to his cousin that he can't make any friends. And he, the cousin's like, ‘okay, you just need to go to the town and like, you know, sit in the square and be open to talking to people. You know, you'll see people wanna talk to you.’ And he’s like, okay. So he goes and he sits in the square, and he got his, you know, his shield and his sword and his three hunting dogs, right? And he comes back and he reports to his cousin, ‘look, I went and I, no one talked to me.’ And it’s like, okay, but how did you show up? You showed up with a sword, a shield, and all these hunting dogs around you, right? So it's not signaling openness, it's not signaling ‘I want to connect.’ And so getting curious about, you know, our body language, our facial expressions, our tone of voice and being able to, and that's where the individual therapy can be really helpful. And actually doing RO is actually pretty fun. 'cause there's a lot of like, you know, like, let's get curious. Let's try to be silly. Let's try to be, you know, there's a lot of irreverence and humor. Try to, you know, change our social signaling to demonstrate openness and fluctuating
Keith Sutton, Psy.D. (40:31):
Yeah. Kinda loosen up,
Alicia Smart, Psy.D. (40:33):
Loosen up. Yeah. It was basically about loosening up.
Keith Sutton, Psy.D. (40:36):
Yeah, definitely. Yeah.
Alicia Smart, Psy.D. (40:37):
It's just like, DBT is for those who feel too much and act too big. <Laugh>, right?
Keith Sutton, Psy.D. (40:41):
Yeah. Yeah.
Alicia Smart, Psy.D. (40:42):
And then RO is like, like, we're trying to loosen up and actually express a little bit of what's going on inside.
Keith Sutton, Psy.D. (40:47):
Yeah. Yeah. Sometimes I think about it particularly, you know, in couples that I work with where like one couple I worked with, she talked about her husband saying there's, there's no there, there he's just like, you know, that, that she needed a more emotional connection. Part of the reason she picked him is because he was so safe and so steady, unstable, and she had grown up in a trauma situation, but now it's hard to feel that connection. And so the way I think about it sometimes it's like the person has the firearm inside of them, but sometimes there's so many walls that you can't feel the warmth. And so kind of helping the person to access that and, and be able to express it and kind of bring that out is a process.
Keith Sutton, Psy.D. (41:31):
Ok, Great. So tell me a little bit about TheraHive and you know, kind of how that works. And I know, you know, for myself, I've learned about the skills. I've read workshops, I've used different ones, but I've almost felt like, oh, it'd be great to even just like go through a DBT, you know, kind of program just to like, you know, kind of get more experience and more focus on that and such. Tell me about that, 'cause I think it has both for clients as well as like some stuff for therapists. Is that right?
Alicia Smart, Psy.D. (42:03):
It does. Yeah. So we actually, so TheraHive, as I was saying, was kind of our COVID brainchild that we released to the world and it is international, like anywhere in the world, you can take the courses and it, it's made for people who wanna learn DBT. And so we do have a track just for adults, and it is the skills, basically the skilled portion of DBT. So you're learning all four modules. We also have a teen program for teens, and now we also have a parent one where a parent can learn tools as well to support emotionally sensitive kids who might have big emotions and who are doing DBT or need DBT. And then, yeah, we went and got APA approval for a CU course for a therapist if they also wanna go through the program and learn to DBT skills.
Keith Sutton, Psy.D. (42:54):
Great. Wonderful. And how similar/different is that to what the clients are going through?
Alicia Smart, Psy.D. (43:01):
So, it's actually a lot -- I mean, some of the videos are basically the same videos, and so yeah, there's a lot of overlap. And so you'll be getting kind of the same course material as if you are participating as a, and then some of the written content is, you know, specified for how to teach, teach DBT and more specified explanation.
Keith Sutton, Psy.D. (43:18):
Yeah. Wonderful. And what are your thoughts on, like, as a therapist who's learning DBT what, what are some of the biggest challenges for folks? I know that you also do a lot of training and supervising, and yeah. And so on. You know, what, have you noticed that's, that's maybe areas that come more easily to folks /clinicians, areas that maybe are a little more difficult? Challenging.
Alicia Smart, Psy.D. (43:46):
Yeah. So I think, I mean, many people I think really resonate with the skills pretty easily. Learning the skills, being able to teach the skills, and practice skills with clients. I think doing the individual DBT work, I think can be pretty intimidating sometimes for clinicians if they don't have the right support. Because the clientele, I mean, it can be depending, I mean, not all clients who need DBT are suicidal or self-harming and, I think that’s the fear sometimes. And yes, DBT is helpful for those people. So I mean, typically, you know, I've been running a DBT center for like almost 15 years now. I would say there's a mix. You know, some people may have those things and if you, if you do have a client with suicidality and self-harm, having the consult group or having a supervisor that can support you with that, because it can, you know, it can be upsetting and stressful when you have a client who's engaging in really high-risk behaviors. And having that support is just so important, you know, to get the training on how to make sure you are not reinforcing anything. And also, you know, how to respond in a way that's gonna be effective and to take care of your own emotional distress, 'cause you know, we're human. We also get attached to our clients and have feelings about our clients. And so it's so important to get support.
Keith Sutton, Psy.D. (45:12):
Yeah. And can you talk about that, because that is an aspect of the DBT, right? Kind of the official DBT kind of approach is that there's the group, there's also the individual work, but then there's also the therapist having a consultation or team or so on to be able to process and, and that support and so on. Tell me a little bit about that.
Alicia Smart, Psy.D. (45:34):
Like, yeah. Yeah. So that is like, if we go back to that idea of comprehensive DBT, those are the four components. They're the group, the individual therapy, the consult team for the therapist, and then also phone coaching, right? So being able to call your therapist to get coaching in between sessions to use the skills. So like you're learning the skills in a group, but then like, are you applying them in your life, right?. And so before you self-harm, calling your therapist, getting coaching, being able to use a skill in the moment is so like, important for skill generalization. But yeah, the, the, the consult team really is about DBT for the therapist. So it is, you know, for us to also practice the skills on ourselves and support each other, but also to allow us and make sure that we're being adherent to the treatment, right? Because it's easy to drift.
Keith Sutton, Psy.D. (46:28):
Yeah.
Alicia Smart, Psy.D. (46:29):
And in some ways, you know, I had a supervisor a long time ago when I was first learning DBT say that like, sometimes you can feel like clients are actually reinforcing you for doing bad therapy or like not holding them to the DBT, right? Because they don't wanna talk about the thing that, you know, they don't wanna talk about their self-harm behavior. They might reinforce you to like, ‘let's just skip that part of your diary card and talk about the thing of the day.’ But that's not gonna help them learn a different way of coping if we don't address the thing. So it's almost like, you know, going where, you know, angels fear to tread like this idea of like, we also have to go opposite that urge to just make it better or make them feel good. And so that's where the consult team is so important, you know, to be able to get that feedback and help to make sure that you're holding yourself accountable and the client accountable to the treatment that's really gonna get them better.
Keith Sutton, Psy.D. (47:23):
Yeah. Well, yeah. And I think for therapists, right, that feels very gratifying to be like the person the person wants to talk to and the listener and the like, you know. Feeling that connection and that like, we're the only ones that can talk about this stuff. But yeah, it's, it's oftentimes sometimes unknowingly colluding with avoidance. Right?
Alicia Smart, Psy.D. (47:43):
Right. And that's why there, again, there's a dialectic within the therapy itself because like obviously, you know, we wanna validate our clients and I think there's the requirement of a certain amount of validation for the client to feel like, ‘oh, you get me, you understand me.’
Keith Sutton, Psy.D. (47:56):
Oh yeah, definitely.
Alicia Smart, Psy.D. (47:57):
In order for you to then even offer a chain strategy. And so that, yeah, it's kind of like that dance again where we're like validating and like --
Keith Sutton, Psy.D. (48:08):
Definitely. And can you speak to the coaching aspect? 'cause I think that's something that I've I know when I originally heard about that or other people are like, Ooh, I don't know if I want to take phone calls all the time. You know, and from clients or, you know, I think sometimes, it may even be at night or, you know, like weekends or, or so on. Tell me a little bit about how that works and how do you manage that? And, and, but I also know it's, it's also a big, big part of it.
Alicia Smart, Psy.D. (48:34):
Yeah. So I, I, it's a great question, Keith. 'Cause I think that going back to your question of like, you know, what might make it challenging for some therapists to go into DBT is this idea of phone coaching and being available. And I will say, you know, one of, again, because of the model and it being flexible, you know, part of the consultation agreement is that we observe our own limits as a therapist. And so, you know, our center has interpreted that and allowed it so that every therapist gets to set their own hours for phone coaching. So like, my hours tend to be like 8:00 AM to 8:00 PM, right? So I'm available-- and I am available on weekends, but after eight o'clock, I'm not available. Right? And so, and if I know I have an event or I know, like, I'm gonna be away; another part of being on a team is that I can get phone coverage, right? So if I know that, like, let's say I wanna go to Tahoe or I wanna go somewhere for a weekend and I, I'm not gonna be available, then someone else can cover for me.
Keith Sutton, Psy.D. (49:34):
Yeah, great. And how often do clients tend to use the phone coaching? Is that something that the client's calling a couple times a day, seven days a week, or it's like once a week? How does that help?
Alicia Smart, Psy.D. (49:48):
Yeah, so I mean, it varies for clients. Honestly. I will say the majority of clients don't use it as much as they should. I mean, I often times have to talk to clients about, ‘Hey, I'm available to you. What's getting in the way of calling me?’ 'cause clients don't wanna bother you, right? They don't wanna, you know, they're concerned that you might reject them, especially if they have BPD, they might actually be fearful that they might be too much because they've been told they're too much by other people. So, sometimes I actually have to do the opposite, like encouraging more phone calls. Now, occasionally there might be one client who tends to overuse it and if they do overuse it, then that's become the therapy-interfering behavior that we can talk about and shape, right? When people are using it appropriately, maybe once a week, I mean it in the beginning it might be a little bit more in terms of like, as they were learning the skill, but the idea is that they become more independent. And part of the phone coaching is that they do need to attempt a skill before they call you. Not like they're just gonna, you know, so sometimes they'll be like, ‘okay, I'm having this issue, I'm thinking about calling, let me try the skill, and oh, it worked. I don't need to call my therapist.’ So, it's a lot less than I think people think.
Keith Sutton, Psy.D. (51:01):
And I think there's also something too around like, how you engage in the phone coaching if they've already, say, engaged in the unhealthy coping?
Alicia Smart, Psy.D. (51:11):
That's right. Yeah. So there's a 24 hour rule, and I'm glad you brought that up. And it does work as a contingency and it's actually incredibly effective. Because clients don't wanna lose, even if they're not using the phone coaching, they often don't wanna lose the potential to have access to you. And so, you know, I've had clients who've actually told me in therapy, like, ‘I didn't self-harm because I didn't want the 24 hour rule to go into effect.’
Keith Sutton, Psy.D. (51:37):
So if the client self-harms, then they don't have the phone coaching available for 24 hours.
Alicia Smart, Psy.D. (51:43):
Yes. Yeah.
Keith Sutton, Psy.D. (51:44):
Does that apply to other behaviors such as, I guess the, the explosiveness, or alcohol, or things like that? Or is it just…
Alicia Smart, Psy.D. (51:51):
It's just for self-harm. Yeah. Just for self-harm and the idea that we want to encourage calling and reaching out before engaging in that behavior. And so once you've done it, there's nothing to really coach. 'cause you've already done the -- you've already solved the problem in an ineffective way.
Keith Sutton, Psy.D. (52:06):
Yeah. That usually kind of, yeah, helps manage the overwhelm or whatever kind of emotions that are going on.
Alicia Smart, Psy.D. (52:13):
Exactly.
Keith Sutton, Psy.D. (52:14):
Yeah. Well, this is great. This is so interesting to hear about and learn. And I know you've been really steeped in DBT for, for so long and also the Radically Open DBT and really kind of bringing that into your work and into the work that you do and the training that you do. And it's so great to hear about TheraHive and really having that as something that makes all of this accessible to both clients as well as to therapists. And is that through a website, an app? Is that-- um, how do folks kind of find it, or sign up, or get going?
Alicia Smart, Psy.D. (52:49):
Yeah, so therahive.com. It is a website, they can sign up and find out more information there, and it's an online learning platform. So yeah, they can check it out.
Keith Sutton, Psy.D. (53:03):
Okay, great. Well, I'll link it in the information that we put up on the website. Well, thanks so much. I really appreciate you taking the time. This was really great. Thanks a lot.
Alicia Smart, Psy.D. (53:13):
Thank you, Keith.
Keith Sutton, Psy.D. (53:14):
Take care, bye-bye.
Alicia Smart, Psy.D. (53:16):
Bye.
Keith Sutton, Psy.D. (53:17):
Thank you for joining us today. If you'd like to receive continuing education credits for the podcast you just listened to, please go to therapyonthecuttingedge.com and click on the link for CE. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, where we provide trainings for therapists in evidence-based models through live and online workshops, on-demand workshops, consultation groups, and online one-way mirror trainings. To learn more about our trainings and treatment for children, adolescents, families, couples, and individual adults, with our licensed experienced therapists in-person in the Bay Area, or throughout California online, and our employment opportunities, go to sfiap.com. To learn more about our associateships and psych assistantships and low fee treatment through our nonprofit Bay Area Community Counseling and Family Institute of Berkeley, go to sf-bacc.org and familyinstituteofberkeley.com. If you'd like to support therapy for those in financial need and training and evidence-based treatments, you can donate by going to BACC’s website at sfbacc.org. BACC is a 501(c)(3) nonprofit so all donations are tax deductible. Also, we really appreciate your feedback. If you have something you're interested in, something that's on the cutting edge of the field of psychotherapy, and you think therapists out there should know about it, send us an email. We're always looking for advancements in the field of psychotherapy to create lasting change for our clients.