Keren Clark, MFT: Understanding DBT

Montare Media presents Season 2, episode 10 of the Discover U Podcast:  Understanding DBT with Keren Clark

JD Kalmenson interviews Keren Clark, MFT to learn about the relatively new therapy called DBT. DBT has been shown to be effective with previously treatment resistant diagnoses like Borderline Personality Disorder and Suicidality. 

Keren Clark is a licensed Marriage and Family therapist who has been intensively trained in Dialectical Behavior Therapy (DBT) and in DBT Prolonged Exposure (DBT-PE) which is a DBT based treatment for PTSD. Keren is also a certified practitioner of Eye Movement Desensitization and Reprocessing (EMDR). In the course of her career, she has had the opportunity to train directly with Francine Shapiro, the creator of EMDR and with Marsha Linehan, the creator of DBT. 

Keren is currently part of the team at the DBT Center of Orange County where she has worked as a DBT therapist and Clinical Supervisor for the last seven years. She continues to train new DBT clinicians in DBT and to actively practice and grow in DBT herself.

Learn More about Montare Behavioral Health: https://montarebehavioralhealth.com/about/digital-library/

Host Kalmenson is the CEO/Founder of Renewal Health Group, a family of addiction treatment centers, and Montare Behavioral Health, a comprehensive brand of mental health treatment facilities in Southern California. Kalmenson is a Yale Chabad Scholar, a skilled facilitator, teacher, counselor, and speaker, who has provided chaplain services to prisons, local groups and remote villages throughout the world. His diverse experience as a rabbi, chaplain, and CEO has inspired his passion and deep understanding of the necessity for effective mental health treatment and long-term sobriety.

Tags:

mentalhealth, trauma, somatics, body-mind, emotionalhealing, DBT, CBT, borderlinepersonalitydisorder, suicide, lifeskills, 

Follow JD at JDKalmenson.com

Transcript

JD Kalmenson:

Welcome to another episode of discover you our podcast exploring innovative and effective solutions to issues in mental and behavioral health. I'm JD Kalmenson, CEO of Montare Behavioral Health, a family of dynamic and comprehensive mental health treatment centers in Southern California. I am so honored and excited to introduce you to our wonderful guest today, Keren Clark. Keren is a licensed marriage and family therapist who has been intensively trained in dialectical behavioral therapy and in DBT prolonged exposure, which is a DBT based treatment for PTSD. Keren is also a certified practitioner of EMDR eye movement descents, and reprocessing. In the course of her career, she's had the opportunity to train directly with Francine Shapiro, the creator of EMDR, and with Marsha Linehan, the creator of DBT. Keren is currently part of the team at the DBT center of Orange County, where she's worked as a DBT therapist and clinical supervisor for this last seven years. She continues to train new DBT clinicians in DBT and to actively practice and grow in DBT herself. Welcome, Keren I am honored and grateful that you've taken the time to be with us today and share your knowledge on this very key cornerstone of therapy. 

Keren Clark: 

Thank you, JD. I'm delighted to be here. I'm really looking forward to it.

JD Kalmenson:

Awesome. To get started for those in our audience who are not familiar with what DBT is. Can you give us a brief description and history of DBT? 

Keren Clark:

I'll do my best to keep it brief. DBT as you mentioned at the top, stands for dialectical behavioral therapy, and it was originally designed by Marsha Lenahan, back in the late eighties, early nineties. She is a researcher and was trying to figure out how to really help people with who are highly suicidal and turns out also to be people with borderline personality disorder, which won't go into too much right now. And really prior to DBT was considered largely untreatable. It essentially has to do with, extreme emotion, dysregulation, inability to regulate emotions and urges and actions associated with those emotions. There's a lot of CBT, or cognitive behavioral therapy in DBT. DBT also has a bunch of other things in it that cognitive behavioral therapy all by itself does not. So DBT has been around and being researched and practiced since she created it. I’m so bad with math these days, but 30 plus odd years.

JD Kalmenson:

Wow. And did it take time for it to become so universally recognized and to be a part of the standard evidence-based treatment?

Keren Clark:

It took a while to get universally recognized, just as any new treatment. It was always evidence-based because that's what she does as a researcher. So it had always had that evidence base. DBT, it's a, both a very straightforward and common-sense approach to treatment. It also is complicated. There's a lot of complications. It's a, a very nuanced therapy. So dialectical behavior therapy, it stands for essentially the idea that it's a behavior therapy, which includes cognitive behavioral therapy. It also is based in the idea of dialectics, which believe me when I first came to DBT I'll lose track of that as well. But in 2003, I'd heard of dialectics didn't really know what it meant. Dialectics essentially is the idea of that they can be to seemingly opposite, apparent opposite things, both of which are true at the same time.

JD Kalmenson:

Hmm.

Keren Clark:

So for instance, I could be really looking forward to this broadcast with you and I could feel a little anxious. And both of those things are true. Neither one cancels that the other, neither one means the other is right or wrong. They're just both true, they coexist. Obviously things can be much more complicated than that as well. It takes a lot to get trained, to be really, really a true DBT therapist. So it took a while to get enough people trained who were actually providing the therapy fully. And then as with any new treatment, any new, anything, the status quo takes a while to accept the new thing. 

JD Kalmenson: 

So that's right, because with DBT you hear about more or so than in other interventions or other modalities of treatment, you hear about therapists who utilize DBT in the midst of their other sort of therapeutic skills, CBT, DBT , narrative therapy, motivational interviewing. But then you hear about DBT specialists or therapists who specialize in DBT. So they're obviously taking it a lot further and their training is a lot more intense, which is what I'm hearing you describe. 

Keren Clark:

DBT is best known in therapeutic communities as a group of skills, which is a part of the therapy. It's not the entire therapy. So sometimes, again, particularly in professional circles, it construed as, oh, it's just a bunch of skills that you learn, which are helpful, and that's all it is. And that's just not accurate. My point is that there is a particular frame of DBT that takes time. That particularly is a thing that takes time to be trained in how to do and how to stay within the frame and how to stay adherent to the model.

JD Kalmenson:

Right. Right. Does it, does it offer a new lens and a new sort of platform for exploring some of the underlying issues and challenges for asking questions within a certain framework? Or is it more innovative on the solution side? 

Keren Clark:

I believe firmly a hundred percent that everybody can benefit from learning the skills of DBT not everybody necessarily needs the whole therapy in order to, as what we call in DBT create a life worth living out of a life that may be in chaos and a bit of shambles, and everyone can benefit from it. DBT is particular in that people who provide DBT therapy, part of the training is to learn and use the skills yourself. So it is a therapy of practice. It is a therapy that I'm doing in my own life and is integrated into my own life. Just as much as I am trying to teach people to use it and advocating for them to use it in their own lives. DBTs, not a therapy where I'm sitting over here thinking, I know this cool thing. I don't need it, but you do. It's definitely a therapy where everybody's in it all the time together. And as a team, as a team of therapists providing DBT, we are in it, we're in it together as well in our consultation team. And in our format and how we conduct our meetings and how we conduct all of interactions with each other, as well as with our clients. 

JD Kalmenson: 

That's amazing. And that makes it very unique in the sense that it's really lifestyle as much as it is a therapeutic intervention to acute precipitating circumstances, medical necessity, or whatnot. A follow up question would be, has DBT fundamentally, or cosmetically evolved since its inception? Is it an evolving sort of modality with new layers and new dimensions of insight that getting covered with it being so widespread and so many people actively participating and contributing to this living tree? 

Keren Clark:

DBT is always evolving and, and there are always new treatments being created that incorporate it, or that are, that grow out of it. And, and all of it for people who are doing it really in truly not just kind of making up their own thing off on the side with a little bit of DBT training is all done in association with Marsha Lenahan’s organization, Behavioral Tech. So for instance, I'm also trained in DBT Prolonged Exposure. Which is a trauma treatment, essentially. Prolonged Exposure's been around for a lot longer than that. And a particular member of our community, by the name of Melanie Harnett of the DBT community, I'm like speaking of our community at large, 10 plus years ago, started working directly with Marsha to create a prolonged exposure protocol that is embedded in DBT, or has DBT embedded in it. So things like that are continuing to happen all of the time. 

JD Kalmenson:

That's amazing. So being that it is a certain skill set, but more than that, it's a certain approach to regulating emotions. Then the more you integrate that into various spheres of behavioral health, you're, you know, DBT is becoming bigger and broader and, and more wide ranging,

Keren Clark:

Correct. And research has again, because DBT is such a, an evidence-based treatment and Marsha Lenahan herself is forever a researcher. So the whole organization is very based in ongoing research. So since its inception, as I said back in the late eighties, early nineties, it has been shown to be effective with substance abuse issues, chemical dependency. It has been shown to be effective with bipolar disorder. It has shown, any kind of emotion regulation disorder in, in addition to say someone who might meet full criteria for borderline personality disorder, it's effective for. It has some effectiveness with eating disorders, although those are complicated and so require additional things that are outside of the scope of, of DBT, but the skills of DBT are helpful for eating disorder folks, So when Marsha Lenahan started putting this together and the brilliance of the mind that she has, what she noticed that was really missing from all from therapy because therapy in general is a, it's a technology of change, right? You go into therapy because you want to change things. What she noticed was really missing was how to be in the present moment as part of the therapy. Again, dialectically speaking how to both accept ourselves, right where we are in the moment we're in and also work on change. One of the foundational dialectics of DBT. And so she actually went to Zen, studied Zen for herself. She originally had actually spent some she's born and raised Catholic and had spent some time very steeped in that, recognizes that there are mindfulness and we of it too, their mindfulness and practices and sort of all, all the great religions, certainly it's not just in Buddhism, but that's where she went. She went and studied with in a monastery and spent a lot of time. And so came back with this idea, which is really how the part of the dialectic got really clearly formed. That what we're really trying to, to find is a middle way, a middle path. There's that sort of balance between whether that be emotions, whether that be how do we figure out, how to navigate if we aren't quite where we want to be yet. And we know where we going to get without just like getting all mad at ourselves, because we're not there yet, but also continue to take steps in that direction. So how to really bring those things all together, and ultimately find some kind of balance in middle way. So if we fall more heavily over in, like I tend to get more angry, than I get sad and we're trying to bring it more into balance. Let's get at what's in the way of your sadness and let's help you learn skills to mitigate your angry behaviors. 

JD Kalmenson: That's amazing.

Keren Clark:

Yeah,

JD Kalmenson:

No, that's, that's, that's so inspiring. If you don't mind sharing, how has DBT changed your life?

 Keren Clark:

I tell my clients; I warn them because I get very enthusiastic cause I may warn you and your listeners as well. I I'm a DBT evangelist. I get very, very excited. I get very enthusiastic about DBT because I've seen it. I mean, I know the research of course, but more than that, I have seen it change people's lives. And I know how it's changed mine to your point. It absolutely changed how I parented.  I gotta say, I think I was a pretty good parent to begin with changed. It made it better. It changed how I interact with peers. It ultimately changed my whole frame of how to do therapy. Like my interest in psychodynamic just was like, like I just no longer. We talk about the, the way we talk about the past in DBT we need history. We need it because we need to understand where our clients have come from. And what's operating now because a lot of trauma for instance happened in the past, but is still impeding our lives now. Right. So we use the past to just help clients to help them validate themselves. Like it's no wonder that you've got these issues right now, going on in your life. No wonder that you struggle with your emotions, given your history, given your trauma, given the traumatic invalidation you experienced in your life. That's it's no wonder.

JD Kalmenson:

Wow.

Keren Clark:

And, and you are the only one who could change it from here.

JD Kalmenson:

That's so thoughtful and it's intriguing. 

Keren Clark:

And this is why people need to learn skills, because otherwise what we mostly do in our culture, even without say extreme dysregulation is we just act, and we react. You say one thing I say another, then you say it. And then I say it, or then right, if we're sort of beginning to have tension, then your tension may rise. And then my tension rises, and you say, and then I say, and then we totally lose track of what our overall long-term goals are with each other or in our lives or in the world. And we get caught in who's right. And who's wrong. And our goal shifts from say, I really want to be a kind person and come across that way to, I want to be right.

JD Kalmenson: 

Yeah, no, that makes so much sense. And the key, the key word here is emotion because I'm reminded of a funny Kenan and Peele sketch. It's a comedy sketch in which, you know, a wife is, is nagging the husband that he's not on time. And he gets all philosophical and scientific. And he says, what is time? And he starts talking about, I could be here and there at the same time. And he's, and she gets all confused in his rhetoric and she lets him go. But in the world of action, in the world of behavior, outside of the domain and the arena of emotions, sometimes the contradiction can never be resolved. I'm either doing the right thing sometimes, or I'm not. But as far as feeling those feelings, that is, you know, the DBT really helps maintain the regulation while feeling these opposing feelings, is that a correct statement?

Keren Clark: 

Right. And it it's trying to maintain the behavior like, because we have, we can have the emotions. Emotions are never the problem. It's the action urges, which includes thoughts, includes words, includes you know, physical actions that are, that can be the problem. But they aren't always the problem, and they can be the problem. And DBT not only teaches skills for how I regulate my emotions. It teaches skills for how to tolerate difficult emotions without making a situation worse, which is the distress tolerance module, learning more about emotions and how to regulate them, how to be more effective. And how we navigate is essentially the emotion regulation module, mindfulness is its own module and underscores everything else. 

JD Kalmenson: 

That's beautiful. I mean the mindfulness just seems so key to me, and you've mentioned this, and you've referenced it because really what, one of the most profound ramifications of mindfulness is the ability for us to have a sense of awareness about what's going on inside of us almost as if we're witnessing it from afar in a detached manner. 

Keren Clark:

Like I really want to, in that example you gave of the, the husband and wife, you know, I really want to smack him upside the head right now because he's talking nonsense. Right. Versus like, but I don't want to treat my husband that way. So like, how do I navigate this?  She might say something like, you know, honey, interesting philosophy. And I'm still really wondering if you can get better at being on time. What, you know, he may go back to the, on time and you know, about time or is it, what is time? And she can go, yeah, yeah. I hear you. And I'm still wondering what can we do to help you be on time tomorrow?  Or, you know, maybe you can give me a call if you're going to be late. It's like, that's called being mindful to your ask or your request. 

JD Kalmenson: 

That's, that's, that's really, really special. And if we can all just integrate a little bit more in our lives of that sort of spirit and that mentality, oh the world would be a, a much better place. If you could perhaps share with us some of those DBT skills. 

Keren Clark:

There are specific skill sets within each module. I can tell you off the top of my head that there are seven skills in the mindfulness module.  Those are just easier to remember, but they're more in each of the other modules than that, so at the heart of it is a skill called “wise mind,” which is, again, one of the initial dialectics of DBT. Wise mind is sort of the middle place between what we refer to. If we're thinking about dialectal extremes, emotion, mind, which is where everything's ruled by heat and emotion, and you can hardly think straight because you're just running on the emotion and urge to act from there. and then what she refers to as reasonable mind, which is again on the extreme sort of devoid of emotion is just logic facts.

And wise mind is the place where both are present. So it effectively, it's the middle path. It's where you can use your emotions as what they are meant to do, which is signals that something's off. It's like, you're putting your hand over a hot stove. It's getting hot, like, oh, something's wrong. I need to, I need to possibly think of a different thing to do besides continuing to put my hand over the hot stove and then also still access our reasonable mind to make decisions based on what is happening in the world around us, what's happening internally and what messages we might be getting from the emotions that are valuable to us. Something's off. Something's not right here. So wise mind is essential and, and is essentially for the very first skill you learn. And it's considered part of the mindfulness module because you have to be able to notice where you're at, right? You have to be able to step back far enough as you were mentioning to see it.It's really about learning how to be mindful in your life. Moment to moment to moment it's like off the cushion, it includes the cushion, but it's off the cushion. How do I be mindful? How do I stay present? How do I stay focused on my goals and what I'm trying to get and also stay here? So the skills are observe, describe and participate.

Keren Clark:

So observe and describe particularly for most of us our time, it's noticing what is happening internally and in the environment and putting words on it for ourselves. We don't have to say it out loud, but it's essentially that stand being able to step back far enough to say, for instance, the husband-and-wife metaphor used earlier. Hmm. I'm still irritated that he was late. Hmm. He's talking about philosophy. Hmm. Right. Just being able to step back and notice all of that. And you're putting words on it in your mind, because we do immediately. Once we learn language, observation and words kind of go together pretty instantly. So observe and describe is key because it's also what we can do to help ourselves come back into that moment. If we're still thinking three days later about the fact that we didn't ever get him to commit to doing better being on time,like we're still ruminating on, oh, that conversation we had and how come I didn't like tell him, but we're still chewing on it. Observe and describe helps us come back. Because we wanted, we need to give our mind something to do. The human mind, particularly the Western mind is like I liken it to a, a puppy in the chew stage. It wants to always be chewing on something. And if you're not giving it something okay to chew on, it's going to chew off all the upholstery on your brand-new couch. It's going to start ripping things apart. That's because it will get up to something. If we don't give it something to do. 

JD Kalmenson:

Wow. Those are profound skills. Wow.

JD Kalmenson: 

Hmm. Would you be able, could you, would you be able to share another one or two of the skills from the different modules? 

Keren Clark: 

Yeah, I'd love to. So, mindfulness, distress, tolerance, emotion, regulation, interpersonal effectiveness. So in distress tolerance, what we're really trying to do is, lower the intensity of, of say an emotion that's gotten really high and we're having urges to act on it in ways that may not be effective and maybe distress, , and how to sort of bring them down a little bit, help us get through a moment that we either can't change or choosing not to change or to help us bring them down enough, to be able to think a little bit more about some of the other skills. Cause when we get extremely dysregulated, it's hard to think.  When our emotions get high, our physiology is responding. Like our breath is short or our heart speeding faster or things like that. So there there's a group of skills called TIP skills. And those stand for tip the temperature, which is a way of, of creating the mammalian dive reflex without having to get into say a swimming pool. And there's one called that. So that's the T. Then the I is intense exercise like literally doing, you don't have to go for a long run. You can, but it can also be like three rounds of 20 football drills that could constitute doing the skill of intense exercise. And then one of the P of tip is paced breathing, which is a longer exhale and inhale or paired muscle relaxation, which is the one where you clench all your muscles and hold your breath and, and then really center. Those literally drop intensity.

Keren Clark:

Also distract is one that we use a lot. So how to consciously intentionally choose things that help us to distract so that we can give our mind so we can use our observe and describe skills as I mentioned earlier, while we're doing that distracting thing to distract ourselves from say a really set emotional rumination and just stay focused on, you know, playing a game on my phone, but you know, keep observing and describing to myself that I'm, you know, making this motion, I'm doing that thing versus kind of playing with my phone and thinking about that thing I'm upset about. So those are a couple from distress tolerance. 

JD Kalmenson:

That's amazing. That is absolutely inspiring. It's practical, it's relevant. 

JD Kalmenson: Would you say off the bat that there are certain folks or clients who might not be candidates or suitable for DBT?

Keren Clark:

There are some things that DBT there's a couple answers to that one is there's not, there's no evidence base that DBT is safe for treating schizophrenia. For example. Now, if you have a client who has some psychosis as a result of say their PTSD or their bipolar, they still might be able to do DBT but say a full-on thought disorder, there's no evidence base for DBT being an effective treatment for that. So mostly we would not say treat someone with a, you know, a full-on diagnosed thought disorder. So a client has to commit to the therapy because it's, it's a therapy of practice. I like to say, it's a therapy of practice, not a therapy of epiphany. It might have some epiphanies along the way, right. That happens. But that's not the goal. The goal is practice, practice, practice. It's really like learning a new language and to implement the learning of a new language you have to practice. So what we are, we need them to commit to that and to understand what they're committing to, not to. Yeah, yeah, yeah. I want to do it. They have to really try to more understand that. And they also have to be willing to take suicide off the table as a solution to their life problems, at least at, for the duration of treatment or, or keep coming back to making that commitment. If they're not willing to do that, then it's not the therapy for that. It's not, it's not that it might not work for them. If they could get it off the table. It’s just, we can't work with them if they're not willing to at least say, okay, I may go right back to it when we're done, but okay. I'm willing to take it off the table. And that doesn't mean they won't have suicidal ideation.

JD Kalmenson:

Right.

Keren Clark:

Just means, so we, we're not saying they don't have to have suicide ideation. We have to say they're willing to not commit suicide.

JD Kalmenson:

Right. I mean, there is a whole new genre today of folks who are treatment resistant and they're looking for interventions that don't rely on their motivation and active participation. Right. And so they probably wouldn't be those that group would probably not be the best candidates for DBT if they’re resistant.

Keren Clark:

Well, and depends on how you're talking about that. So, you know, if we're talking about say treatment resistant depression, which is actually just shows that like all kinds of medications and things don't work, we've had lots of clients who have treatment resistant depression and still benefit from DBT.

JD Kalmenson:

from DBT. Yeah, right.

Keren Clark:

 People who may be saying really just don't want to do the work. They really want someone else to do it for them. Yeah. They probably would not be good candidates. 

JD Kalmenson:

Right, got it. And that’s a great distinction there. 

JD Kalmenson: 

Right, right, right. I, this is, this has been incredible. I’m reminded by a quote from Thomas Freedman from the New York Times. And he says something to the effect of when you press pause on a machine, the machine stops, when you press pause on the human being, the human being starts, or DBT starts and that mindfulness and that ability to see, to feel and to act in a way that's more aligned with values. Even though there are these opposite or opposing sort of sentiments and inclinations, it all comes together. Thank you Keren so much for giving us a really comprehensive and enlightening look at DBT therapy. A lot of folks have heard about it, but I think those who listen today will walk away with a completely different level of understanding its details, how relevant it is and how we can all benefit from it. It was really great having you here with us and thank you for taking the time. How can folks out there find out more about you and the work that you do? 

Keren Clark:

So probably the best way to, for find me and find us at DBT Center of Orange County, is our website is DBTCenterOC.com., and if someone wanted to email me on KClark (my last name) at DBTCenteroc.com. There's all kinds of information about DBT. One of the best sources is going to be Marsha Lenahan’s organization, behavioral tech, and that's behavioral tech T E C H, TECH.org. And I also want, even though we didn't have time, but just for people, if you're curious to look into as well some of the skills that are part of emotion regulation module, and interpersonal effectiveness module, just a quick pitch for interpersonal effectiveness module of DBT. The way that Marsha Lenahan put it together is revolutionary. And that is my favorite skill set. And it's the one that changed my life the most. 

JD Kalmenson:

Amazing. Has there been a book for the layman, for the masses really just breaking DBT down into soundbites or into a sort of guidebook that everybody can tap into? 

Keren Clark:

Marsha Lenahan’s memoir, which is just called “Building A Life Worth Living” is so moving. And it is a beautiful insight into her and her journey. And also really does kind of help set up sort of give you a feel for the skills of DBT. It's a memoir, so it's not like she's breaking it all down that way, but you kind of get a feel for the whole therapy and sort of its genesis and, and where she took it. 

JD Kalmenson:

 I can't wait to read it. That sounds, sounds so interesting. Thank you audience for joining us too. Hope you enjoy today's episode of Discover U. At Montare, we want you to know that you're not alone on your journey, and to find out more about our innovative treatment programs, you can find us at Montarebehavioralhealth.com, and you can listen to our Discover U podcast on iTunes, Spotify, or wherever you get your podcasts. Wishing all of you radiant health and as safe and fulfilling day. See you next time.