Tell us about you and your interest in DBT.
I’m a licensed clinical social worker, trainer, and author based in Oakland, California where I live with my spouse and two cats. I specialize in culturally responsive care for psychotic spectrum disorders, trauma and PTSD, and the LBGTQ+ community. I’m also the Training Director for a Post-Master’s Fellowship program where I take a lot of pride in developing and mentoring the next generation of social workers.
I learned about DBT about 13 years ago when working to help people transition out of institutions and back into the community. What drew me to DBT was its development by someone who herself struggled with severe emotion dysregulation problems. Dr. Marsha Linehan, the creator of DBT, shared that when she was hospitalized as a young adult while struggling with suicide and self-harm, she made a pledge that if she got better, she would devote her life to helping others get out of this same hell. The lived experience that drove Dr. Linehan to develop DBT really spoke to me because I believe it’s critical to have treatments developed by and for the communities they serve.
Why DBT for psychosis? What's most important for therapists and clients to know?
People with Psychotic Spectrum Disorders (such as Schizophrenia or Schizoaffective Disorder) face significant barriers to accessing quality mental health treatment. More so than almost any other group, people experiencing psychosis are consistently overlooked by the mental health field as well as by society in general. As an example, when you look at the majority of psychotherapy research, you’ll find there’s almost always a rule out for psychosis. This has resulted in an almost exclusive emphasis on psychiatric medication to treat psychosis and overall avoidance of using psychotherapy or skill building to help people experiencing psychosis.
Recently a treatment called Cognitive Behavioral Therapy for Psychosis (CBTp) with a strong evidence base for helping people with psychosis has become more commonly used. I was trained in CBTp which I love and use regularly, but I felt like it lacked the types of concrete tools DBT offers to people when they’re emotionally overwhelmed. People with psychosis often get caught in a vicious cycle where their strong emotions make it more likely their psychotic symptoms will worsen. And then their symptoms tend to cause their emotions to escalate even more. For example, you might feel really ashamed after getting reprimanded at work. As a result of this increase in emotions, your psychotic symptoms are more likely to get worse, such as hearing distressing voices saying critical things to you. In turn, hearing these critical voices are probably going to make you feel afraid or sad and you’re then more likely to isolate yourself from others. This cycle just continues until we find a way to break it which is where DBT skills come in.
One way to think of DBT skills are as tools you can use to take back control of your life from your emotions. They can help you be more mindful, improve your communication skills, and get through a hard moment without doing something to make it worse. DBT skills do a really great job of helping reduce suicidal thoughts, self-harm behavior, PTSD, and drug use, all of which are very common amongst people experiencing psychosis. DBT is ultimately about helping people build a life worth living. That’s a powerful concept. Rather than simply doing suicide prevention with the goal of keeping you alive, DBT is about giving you a reason to fight for your life, a reason to do the work and stay motivated. I love that about DBT.
I started a DBT skills group for people experiencing psychosis in 2014 in an effort to make these skills available in a more accessible and concrete way. Offering simplified DBT skills to people dealing with psychosis helps them deal more effectively with emotional overwhelm, suicidal thoughts, drug use, and work to build a life worth living. I typically use it as an addition to CBTp and/or medication management.
Why should clients experiencing psychosis remain hopeful?
Recovery is absolutely possible! I’ve worked with hundreds of people experiencing psychosis over the last decade and have seen many of my clients go on to build careers, graduate college, live independently, have children and meaningful relationships, and generally build the lives that they want. The path isn’t always easy though. I really believe that the key ingredients for recovery are taking good care of your mental health and building a strong support network you can call on when you need it.
Self-care is unique for every person and can take the form of taking medication regularly, getting enough sleep, reducing drug use, engaging in therapy, doing activities that bring you joy, or using coping skills like from DBT to manage your emotions and stress. Your support network is where community-care comes in, meaning the people you call on for support when you need it so you don’t have to shoulder the burden alone. Creating a support network means building solid relationships with family, friends, colleagues, and/or mental health professionals.
Psychosis is similar to other chronic medical conditions where ongoing daily maintenance work is required to keep yourself healthy. While things may look different in your life now then you originally envisioned them, that doesn’t mean you can’t still have a life that’s worth living. The fact that you’re even reading this is already a positive step in the recovery journey!
What do you wish family members knew about the treatment of psychosis?
Helping your loved one who is struggling with psychosis can be tough. When I work with families of people with psychosis, they often talk about feeling powerless over their loved one’s struggle. In addition, they commonly talk about being burned out and how caregiving is impacting their own mental and physical health. Feeling overwhelmed when you’re caring for someone else is unfortunately very common.
A lot of times what I see contributing to family member’s burnout is when they consistently push past their own limits. While it makes total sense to want to be there 100% of the time for your loved one who is struggling, it’s going to inevitably take a toll on you. Caring for yourself is critical as a caregiver and DBT skills can also be really helpful for you. They can help you stay in the moment rather than ruminating on worries about the future, be more patient with your loved one when they’re suffering, and learn to set healthy limits to protect your own mental health. Remember that recovery is a marathon, not a sprint, so the more you and your loved one both utilize self-care as well as your support network, the better off you’ll both be on this journey.
In your book, you talk about a wellness plan. What's a wellness plan?
A wellness plan is a tool to help anticipate your mental health needs and identify the people who can support you in getting these needs met. Similar to an emergency preparedness plan for a natural disaster, your wellness plan outlines what to expect when your symptoms get worse and how to intervene to prevent a crisis.
When creating a wellness plan, you first think through changes in your mental health that suggest worsening symptoms could come if you don’t intervene, such as changes in your thinking, behavior, or mood. For example, you might notice early warning signs such as sleeping significantly less, frequent suspicious thoughts, or hearing bothersome or distracting voices. Next you identify what’s helpful when you notice these changes such as working to reduce your stress, using self-soothing skills, calling a crisis hotline, or getting a medication adjustment. Lastly, you consider who from your support system you’d like help from to ensure you take care of your mental health needs. After creating your wellness plan, I recommend giving a copy to the people in your support network.
A wellness plan is an example of the DBT skill called coping ahead. Coping ahead involves creating a plan of how you’ll deal with a situation you’re worried about so you can feel better prepared and therefore less anxious about the future. A wellness plan has you prepare for the worst-case scenario of another mental health episode which can increase your peace of mind that you have a plan in place if it were to happen.
What is your favorite DBT skill to use?
One of my all time favorite DBT skills is alternate rebellion. Growing up, I was constantly rebelling against the traditional expectations around gender and sexuality that the place I grew up put on me. Sometimes the way I would rebel though would come with consequences that I didn’t really think through such as getting a tattoo which I’m left with the rest of my life. The skill of alternate rebellion acknowledges that we all need to rebel sometimes, whether against an institution, your family, conformity, boredom, or something else entirely. The idea is to find something relatively harmless that still feels like you’re breaking the rules but doesn’t come with negative consequences for you.
Now that I’m an adult, I still have that same rebellious spirit, but I’ve learned to rebel in ways that are more in line with my long-term goals. For example, when I get frustrated with the limitations of the mental healthcare system, I participate in protests, sign petitions, and advocate for my clients. Alternate rebellion reminds us that rebellion can be really fun, and there are plenty of ways to do it safely.
What are you currently reading?
I’m reading Homecoming by Yaa Gyasi which explores the stories of two sisters in Ghana and their descendants through eight generations, winding through the legacy of slavery as well as the history of African and African-American resilience.
Congratulations, Maggie!
You can find The DBT Skills Workbook for Psychosis: Manage Your Emotions, Reduce Symptoms, and Get Back to Your Life by clicking here.
For additional information about DBT, check out:
DBT Self-Help