Building a Life Worth Living: Understanding Dialectical Behavioral Therapy with Stephanie Fennell MS, LCPC

Sabrina Duong LCSW and Stephanie Fennell , LCPC dig into dialectical behavior therapy, exploring how structure, skills, and validation help people move from crisis to a life worth living.  In the episode they compare DBT-informed work with a therapist versus with the full model and take a look at BPD, suicidality, and real-time coaching support.

• defining dialectics and why two truths matter
• how diary cards and behavior chains drive change
• DBT-informed practice versus full DBT program
• coaching calls, weekly homework, and skills group
• Borderline Personality Disorder (BPD) as trauma-related and how its actually a wide spectrum
• life worth living goals for suicidality
• mindfulness, wise mind, and radical acceptance
• emotion regulation and distress tolerance in action
• interpersonal effectiveness to reduce triggers
• access, licensing states, and commitment expectations

Stephanie is a licensed clinical professional counselor with more than 10 years of experience specializing in trauma-focused and is a DBT-trained therapist. She is licensed in Kansas, Missouri, and Massachusetts and is EMDR-certified and trained in Prolonged Exposure therapy. Stephanie owns a private practice, serves on a certified DBT team, and has extensive experience training clinicians and leading DBT consultation teams. She also teaches continuing education courses for therapists on suicide prevention, ethics, and trauma interventions.
Visit smfcounseling.com to learn more about Stephanie’s DBT services. Licensed in three different States such as Missouri and Massachusetts 

Trigger note:  This episode includes discussion of suicidality in the context of mental health and recovery. While the topic may be difficult, the focus is on resilience, seeking help, and hope. Listener discretion is advised. 

Transcript

Sabrina Duong (00:44)
Hi, you're listening to Sabrina Duong at What Would Sabrina Say? And today we have ⁓ guest Stephanie Fennell with us, a licensed mental health professional. We're here to talk about dialectical behavioral therapy or otherwise known as DVT and the way that it can benefit ⁓ clients So thank you so much, Stephanie, for joining us today. Looking forward to talking about it. If you'd like to just share a bit about yourself.

Stephanie Fennell (01:09)
Absolutely. Thank you for having me.
I'm a licensed professional counselor. I've been practicing for
10 years and have experience in what we call dialectical behavioral therapy for the past five years or so. I've been specializing in that both in private practice and in community mental health. I left community mental health a couple years ago to become more specialized and working in DBT full time, both in private practice and within an organization. And so yeah, it's been really a journey of figuring out what I'm passionate about. And DBT is where I landed. I wasn't really playing on it. It just kind of fell in my lap.
So yeah, I'm trained in some different trauma therapies as well, EMDR, something called Prolonged Exposure, which is another trauma therapy. I was trained by the VA for that. And I've led consultation teams with DBT, also been at what's called the team lead, where you're over a team of other therapists So I've kind of experimented with all different sorts of roles but have found where I find most joy is helping people who need to do the work with DBT. And then more recently I've also started helping therapists by teaching CEU courses. So I've broadened my horizons in that way.

Sabrina Duong (02:36)
So I'm going to start off with talking about what is dialectical behavioral therapy and what are some ways that it can help.

Stephanie Fennell (02:44)
Yeah, so let's just start with the words, I think, because they're kind of a little more unusual, right? Dialectical in of itself, like what does that mean? And so I try to simplify that term by just explaining it really easily by saying that it means that two things can exist at the same time. So dialectics really is the idea that we can feel sometimes both somewhat happy and sad, or something can be a relationship that maybe we feel like drawn to, part of us wants to be in relationship and other parts of us are feeling perhaps a bit hesitant or concerned about our relationship. There may be a conflict that we're feeling about situation or relationship that would be a dialectic. So dialectics is really the idea that two things can exist at the same time even if they feel contradictory or in opposition to each other and that's what the word dialectics means. So with dialectical behavioral therapy we really focus on dialectics that two things can exist that we can experience conflict and we can notice that conflict we can notice that two things can exist that are seemingly contradictory to each other. And that can allow us to not feel like we have to only pick one side of the situation or of ourselves. The second word is behavioral, which DBT falls under the umbrella of cognitive behavioral therapy. We're kind of a small offshoot within the larger scope of cognitive behavioral therapy. So we focus on behavior.

We focus on working on behavior through behavioral therapy, which is really how can we use ⁓ really practical tools to help shape and change people's behavior? And so those are the main pieces of what it is in the way of how that term is used. And then how can it help people? I would say the combination of working on becoming more focused on learning skills. That's a big focus of DBT is we're very skill-based and whereas cognitive behavioral therapy can be more generalized in skill building, DBT is very specific. So we teach skills based on needs. So we have different ⁓ modules that we teach and what we have a two-hour skills group that we have our clients attend and those modules are very focused. So we have different areas of struggle or issues or problem behavior that someone might have. We teach them specific skills. So when they're going through a certain type of issue or problem, they know what kind of skill to use instead of applying the same skill to all areas.

So I think when someone has problem behaviors and they maybe aren't finding effective treatments with more generalized treatments, DBT is more specialized and specific. We also really help with people who struggle with something called emotion dysregulation. And really that's just a pretty fancy way of saying big emotions that you have a hard time working through or regulating. And we use both skills and something called validation, which is just learning how to accept and feel those emotions.

Sabrina Duong (05:49)
All right, so it helps in a few different areas when it comes to motion regulation. I like how it also incorporates the nervous system in the sensory base And how it can coexist. We can have issues exist and also find ways to deal with them or see them differently or accept them.

Sabrina Duong (06:13)
So there is a difference between maybe finding a counselor who's DBT informed and has learned about it or uses some of the tools and someone who uses the model as a therapist. I'm wondering if you could talk about what the difference is and what that looks like. Should someone be interested in trying out DBT for themselves?

Stephanie Fennell (06:34)
Yeah, absolutely a lot of therapists will say they're dbt informed, which is wonderful. And what that means is that oftentimes they have learned about some of the components of dbt, they've perhaps gone to trainings or read books and they have gathered information and they like to apply it to their therapy, which can be wonderful and helpful to the clients they see and they may sprinkle it into the work they do, whether it's talk therapy or CBT or psychotherapy, things of that nature. And so they will say they're DBT informed. That's quite different though than being DBT trained or having that be your focus in the work you do. The actual modality is very structured.

And so a DBT session is actually not going to be talk therapy focused at all. It's going to be focused on something we call diary cards. It's going to be focused on what we call behavior chain analysis. So a DBT therapist is actually going to have a very different approach to how they do a session than someone who is DBT informed, where they may just offer those skills when it's appropriate ⁓ through their talk therapy lens.

And so making sure that your needs align with what your therapist offers can be quite important. If you're really looking for a DBT-trained therapist, you wanna make sure that that's what your therapist is offering, because sometimes that can be not aligned, and then you're kind of gonna be struggling to feel like your needs are being met or that you're really getting what you want with a DBT approach to therapy.

Sabrina Duong (08:18)
Great, so it's helpful to understand the difference and know. Or discover what would be most helpful for you, depending on goals.

Stephanie Fennell (08:25)
Yeah, and maybe learning to ask questions. Sometimes I think when it comes to therapy, we view the therapist as the expert and we look to ourselves as the client, ⁓ as perhaps coming to the therapist for help and, they know what they're doing and I'm just gonna go with the flow. And so I think becoming more of an advocate for yourself is important and asking the question. So how do you use DBT? What does that look like? What does it mean when you say you use it? What kind of training do you have? So being a bit more intentional about asking your therapist what it means to have a DBT approach and how they do it, do use it in session can sometimes give you more indication of what type of approach they use and how much DBT they use.

Sabrina Duong (09:09)
Right, so we've been asking, is there home practice? diaries? Is there coaching being offered?

Stephanie Fennell (09:13)
Yeah. Good. Yeah, that's another point of coaching calls. A true DBT therapist is going to provide coaching calls. All of my DBT clients have coaching calls with me. I assign them homework every week. That's something else you're going to get with a DBT therapist. We're going to go through the workbook. there's going to be ⁓ skills that you learn every week. So it's going to be a lot more rigorous. it's kind of like going to school. It's just DBT school. So ⁓ while, there's, there's value in talk therapy. I've gone through talk therapy myself, you know, I appreciate it. it's just a little different than a DBT structure.

Sabrina Duong (09:51)
Right, and then wondering how can dialectical behavior therapy help with maybe different diagnosis? So someone maybe who's diagnosed with borderline personality disorder, I'm wondering if we could talk maybe what that is and how it can be helpful.

Stephanie Fennell (10:05)
Yeah, I think knowing about BPD is the first step. You know, sometimes having the diagnosis itself can be challenging. I've had clients come to me who've had therapists who've been resistant or even just hesitant to diagnosing them. And so they've struggled to even get the proper diagnosis. There's also a stigma around BPD and that's also challenging. So

Borderline personality disorder is now what we call a trauma disorder. In the past, it's been labeled a personality disorder. What I mean by trauma disorder is really, it's something that evolves out of a person who has had a history of trauma. And so it impacts a person's ability to function, thrive because of their trauma history. And we know that it impacts ⁓ emotion.

regulation or ability to regulate and process emotions. We know it impacts ability to regulate behavior. So there's a lot of behavioral dysregulation that can have a whole variety of, you know, expression. So anything from ⁓ struggling with substance use to relational struggles, like with, you know, interpersonal issues from, you know, romantic partners to family as well as people struggling with jobs, managing jobs successfully, or even struggling with impulsivity, whether it be food issues or impulsivity around finances. So it's hard to really describe it in one sentence because it can look so different. Another thing I like to say is it's a spectrum there can be a whole gamut of how it is expressed in a person. So not it's not a one size fits all.

And so I've had some clients who can be what we call like high functioning and whether that they live, they have high successful jobs. They are able to maintain their lives in a very successful way. They still struggle. They struggle with self harm. They struggle with suicidality in the way of having urges, But they're able to mask pretty well in their jobs. And then I have other clients who struggle with keeping jobs successfully and they have a substance use history and really struggle to keep a lot of those stable pieces in life. BPD is a disorder that can really impact life differently for different people. We know it starts typically in the teen years, not always, and it can take quite a while to get diagnosed.

Sabrina Duong (12:31)
Right, I'm wondering if we can talk further about how dialectical behavior therapy can help with suicidality. And I know that's a hard topic for people to discuss, but people do have thoughts of suicide and stressful times, especially the holidays and it might be helpful to share how dialectical behavior therapy can help with those thoughts.

Stephanie Fennell (12:41)
Yeah. Mm-hmm Yeah, I agree. This can be a vulnerable time of year for a lot of people. The holidays can be really challenging. For some people, it's a positive time of year. For others, it's a vulnerability. And a big reason that dialectical behavioral therapy was even created was for suicidality. so unlike, I would say, traditional therapy, psychotherapy, a lot of the function of it with suicidality is to reduce people's urges and to reduce the vulnerability for wanting to die, which we know is helpful. We know that serves a purpose. I would say what sets DBT apart is we really work on creating a life worth living goal, and we work towards that goal. So we're not just trying to reduce the vulnerability of suicidality, right? We don't want people to die, that's important. And we also want to create a life they want to live. Because when people struggle with suicidal urges, it's not just about trying to reduce that vulnerability, it's, well, what's the point of reducing that vulnerability if they don't have something to want to live for? And so we really try and increase that motivation so that we're... looking forward and towards something, not just reducing the safety vulnerability of suicidality.

Sabrina Duong (14:14)
And what's helpful about this model of intervention is that, there are steps, there are processes to help work through. It's not short-term cookie cutter. It is a commitment as well.

Stephanie Fennell (14:28)
Yes, most definitely. And I don't think I even answered your question about BPD, which I got very focused on the diagnosis because I'm so passionate about it. BPD really is a diagnosis that people struggle to find success with traditional therapy in. so dialectical behavioral therapy is the only therapy that is actually evidence based for borderline personality disorder.

So for people who have that diagnosis and want to find breakthrough, want to find benefits of change, this is a therapy for them. This is what they're going to find actually helps them to get well. And for people who have that disorder, can be very, it's increase of suffering is so significant because you just feel stuck. And when you're seeing a therapist year after year and you're not getting well, it becomes so discouraging. And so this therapy is... is what has been created for this population specifically to help them actually have hope that they can get well, that they can stabilize, that they can have breakthrough. So I just want to mention that because it's so important to give people with BPD hope because I think so often they get stuck seeing a therapist who maybe doesn't specialize in DBT and then they feel like they're just not ever going to get better. And so, yes. ⁓

It's a very structured timeline. We asked for your commitment for on the front end. Now, if you need more than a year, you can re sign up. But we asked for that commitment. It's not like talk therapy where you you go you start and then you kind of stop when you want, right? It's just kind of free flowing for the most part, you know, ⁓ acts for your commitment when you start seeing your therapist, whereas with DBT, ⁓ after you do that initial for we call it for sessions of orientation where you really learn about the therapy, what it means. We want to make sure that clients are fully aware of the commitment they're making, make sure it's the right fit for them. Then we ask for that your commitment, mainly because we want to make sure that we're in it together, because it is a lot of work and it is a big commitment. And so yeah, there is a timeline and then we reevaluate. So that's what we call stage one. Stage one is where we work on those behaviors, those unhelpful behaviors that our clients are trying to work through. And then what we call stage two is where we work on the trauma that kind of set our clients in their patterns to begin with.

Sabrina Duong (16:46)
Right, and dialectical behavior therapy can help not only with maybe a diagnosis of a mood disorder, but addiction. I've had training experience around eating disorder, as well as ADHD, and wanted to see if you're able to kind of, I know we don't have a whole lot of time, but touch on how it might be helpful with addiction or eating disorder.

Stephanie Fennell (16:57)
Mm-hmm yeah, that was actually my first experience with this therapy. I was working in outpatient co-occurring substance use disorder treatment and it was so discouraging because we would have them do the treatment. They would finish, they would graduate and they'd be back six months later. And it was like, what are we doing wrong? Why isn't this working? And so someone suggested, well, maybe we need to learn DBT.

And so I got trained in it and we started offering it. And before you know it, clients were getting well and they were staying well. And we were like, this is so wonderful. It's so encouraging. and we had a wait list. And so, yes, this is a very effective treatment for people who have substance use disorder because it's very focused on behavior. It's very focused on skill-based. And there's that real time piece with coaching calls, where you're able to call in when you need it and ask for support. A big part of why I think a lot of people struggle is they don't have that real time support. They have to wait in between sessions for their next appointment. Whereas in their day to day life, they may be having an urge or something and they need that support where with DBT you can use those coaching calls to reach out to your therapist and they can offer skills, suggestions, skill support when you need it.

So that's something that I think has been so beneficial for people who struggle with substance use disorder, as well as mood disorders. We know there's also a huge connection between people who struggle with BPD and eating disorders. Eating disorder community really also struggles with, I would say finding long-term success. There's a huge ⁓ vulnerability for relapse in that population as well. ⁓ Yeah, there's different groups that also find benefit to this, not just people with BPD.

Sabrina Duong (18:55)
Yes, and what I really like about this model is you're exploring with a person, you know, let's say how their senses or is there over stimulation, right? Biopsychosocial, looking at, you know, history, socially what's happening and you're just kind of exploring together ways how, the body responds, how there's behavior, how we perceive things, our environment and ways to feel safe and even using the slogan like life worth living and how DBT treats chronic hopelessness is one where you could talk about like what's that difference between being able to understand that there's life worth living and being helpless or hopeless about things or hopeful.

Stephanie Fennell (19:44)
I think something that I've learned within my work with my clients specifically in the last three years we'll say is how to engage in a curiosity with people who struggle with hopelessness and learning how to meet them in that care and that hopelessness with a place of validation, a big piece of what we do with dialectical behavioral therapy is validate where someone is. Oftentimes, I think the urge that occurs in therapy is to want to push for change when someone's hopeless, when someone has chronic depression, when someone has chronic suicidal urges, we want to just kind of skip over where they're at to kind of get them where we want them to be because we're like, this is uncomfortable. It's uncomfortable to hear someone talk about wanting to die.

It's uncomfortable to sit in that place of hopelessness. Yet what I've found is that's really what's needed oftentimes is to learn how to actually sit in that place with someone. What does it mean to be curious and nonjudgmental? And in that space of nonjudgmental approach, we find that there's almost this ability to let go and in that place of

what we call radical acceptance, which is a skill we use in DBT, then someone can actually be open to change. And so by not skipping steps, so to speak of curiosity, non-judgmental stance, that allows us as both therapist and client to be willing to want to engage in change instead of kind of pushing for it and kind of bulldozing to change through skipping steps, if that makes sense.

Sabrina Duong (21:34)
Right, and what I really like about this model of intervention is understanding, like, as human beings, it's hard to accept things or let go, especially when it's such a stressor involving, you relationships, whatever it is, something that we're not wanting to change. And it's a real great model to help with those areas, right, of accepting and how to sit through.

Stephanie Fennell (21:57)
Mm-hmm.

Sabrina Duong (22:00)
Uncomfortable feelings and ways to regulate emotions. I'm wondering if you can share a bit about that, how it helps introduce those techniques, distress tolerance, emotion regulation versus maybe traditional therapies.

Stephanie Fennell (22:17)
Yeah I think, you know, talking about some of these topics is oftentimes the on ramp to then learning these skills. I've had clients tell me no one has ever wanted to talk to me about wanting to die before. I've not even talked about this with my therapist or my psychiatrist. So me being willing and me just the DPT therapist, right? I'm just one as a DBT therapist saying, hey, I'm willing to have this conversation. I wanna know, I'm curious, I'm interested. Like tell me more, know, actually letting them have a place to open up I think is the first step to then learning and teaching skills. Because oftentimes people who are suicidal or have those emotional dysregulation issues, they feel so closed off to talk about hopelessness and suicidality, but they don't have anywhere else to talk about it. And so there's this like openness to learning skills when they know they can talk about these things freely and even in detail without fear of judgment, without fear of reaction, without fear of hospitalization because they feel safe. So creating safety is to me is the first step. And then really focusing on simple tools that help with not just function of skills. And what I mean by that is like, you know, breathing exercises or mindfulness skills, right? These like external functions of skills. really, step one is how does your body feel and learning to connect to that emotion in your body. With DBT, emotion regulation starts with that kind of stillness of like, what is your body feeling and learning to name your emotion, identify it, validate it, and then learning skills of how to regulate it. Oftentimes we want to skip steps. We want to just push the emotion down and push it away by using skills. And all that does is cause that emotion to come back more intensely because when we push things down and we push them away, they just pop up more intensely later because our emotions have function. And that's a big thing we teach is the function of emotion. What is the function? It's communicating with you. There's a reason you're feeling this feeling. Let's explore that. And that's what we do with a lot of the tools like we call behavior chain analysis. We analyze the function of behavior and the function of emotion.

Sabrina Duong (24:45)
That's great. And what I also like about this model is helping a person to navigate interpersonal relationships that may be affected by challenges of regulating emotions or, challenges in mood and the chronic hopelessness. And I was wondering if you can touch a bit about that as well.

Stephanie Fennell (25:07)
Oftentimes our emotions, how we're feeling about ourselves are like a ripple effect into our relationships. And so with the module we teach on interpersonal effectiveness, we're teaching skills on how to really be more effective in not only communicating what we need and want in relationships, but also getting more of what...
we want from others. And so it's this give and take of how can I be more effective in communicating limits and relationships and also communicating when I'm having emotions that are uncomfortable for me. And so that's that module can really help with those emotions in and of themselves because if I'm ineffective in my relationships, often that can be a prompting event for my dysregulation. becoming more effective with the relationships can really help with resolving a lot of the prompting events that activate us when we're feeling a lot of high emotion. So becoming more skillful in our relationships is such a key for all the other areas that we're trying oftentimes to work on when we talk about unhelpful behaviors.

Sabrina Duong (26:16)
So it helps with developing several different skills. I also find it helps with that acceptance piece using what they call wise mind and mindfulness to just be more present, not maybe, respond from emotions or maybe react in ways that we're not wanting to. I was wondering if we can talk about  what that all means, your mindfulness and acceptance. Sometimes those words can kind of be thrown around, but how does it apply within DBT?

Stephanie Fennell (26:49)
Yes, I feel as though mindfulness is very focused on and a lot of mental health these days. yet the approach is oftentimes I think the idea of mindfulness can be meditation. That's what we think of when we think of mindfulness. Yet, when we teach mindfulness in DBT, it's a whole variety of behaviors, not just my meditation. Now that can be one way you engage in it, but really when you break down the concept of mindfulness, it's going to be present in the moment. And there are lots of ways you can engage in being present. And for some meditation isn't the most effective way to do that. So we try to help our clients find the most effective way for them to learn to be more present.

The belief with DBT is that being present in the moment is the foundation and everything else is built upon that. So we teach mindfulness more often than any other skill, because if you're not present in the moment, then how are you gonna be effective with your emotions or with other people or when you feel overwhelmed, right? So we really hone in on mindfulness. encourage practice. Again, that's where that homework comes in is practicing mindfulness regularly and finding creative ways, not just one way, but multiple ways you can engage in mindfulness day to day. And we really try to encourage it to be a natural, meaning like not something where you have to pull away from your life, but you can integrate it into your life. So it's more natural and not so forced. And so ⁓ there's lots of skills that we teach in our skills handbook that try and give our clients more insight into how they can integrate mindfulness as we call it a practice. I think another thing is people very judgmental about themselves like, I'm just not good at it. And it's like, well, it's a practice. I say, you know, we're not good at riding a bike when we first learn, right? It's something we have to practice until we get good at it. And in the same way.

We have to practice mindfulness, especially in a society where we are on technology all of the time and we do so many things that distract us. so mindfulness is something we're just not gonna be, no one's gonna really be inclined to because it's not something that as a society we really value. We tend to try to distract quite often.

Sabrina Duong (29:13)
Yeah, so a lots of great tools and ways to practice being more present, more aware, trying things out with intention and helping to improve mood or maybe using different coping tools than in the past. So it's a really great model of intervention. I was wondering, where can people find you to learn more or to connect? if there's anything else you'd like to share about DBT.

Stephanie Fennell (29:37)
Yeah, I have a website. It's www.smfcounseling.com. And I have a private practice where I offer DBT and private practice. And I do the model. So again, I offer it virtually. I provide it. I'm licensed in three states, so I can do it in Missouri.

Kansas and Massachusetts, so that's important. ⁓ Those are the states, you have to live in one of those states for me to offer therapy for you. And something I think is also important to know about DBT is that there's a commitment of weekly therapy. A lot of times when you see a therapist, you go every few weeks or once a month. And so when you tell someone, you have to commit to weekly sessions, they're a little taken aback, yet...

The function of that is so important because in order for you to learn skills and to work on some of these behaviors that you want to change, you have to be consistent in seeing your therapist, analyzing your behavior, looking through your diary card, which really is just a way for us to track your emotions consistently. There has to be consistency in meeting. And so that's also a difference I would say in DBT compared to other therapies that are perhaps a little bit more free flowing as far as structure.

Sabrina Duong (30:58)
Right, it's a commitment, but a commitment to yourself, right? And making changes that you're wanting to see. And of course you have someone's support, like yourself along the way. And how great to have that coaching piece and to have someone there weekly
working out a different muscle and fortunately we lose momentum if life gets busy or things kind of get in the way and it is, intervention. So ⁓ it's a bit different than if someone may be coming with milder symptoms of depression versus more severe.

Stephanie Fennell (31:19)
Mm-hmm.
Yeah, I would say it's an investment.

It's an investment in yourself and when you may have been stuck, like I've had clients sometimes who've been stuck with some of the same unhelpful behaviors for decades. And they just now have realized they perhaps have BPD. And they need true DBT, you know, yes, it's an investment of a year commitment and this could break some of those years and years of patterns of behavior that you've wanted to see change, yet you haven't had the tools. So it's like building, we call it a house, a house of tools so that you can then continue to steward that house and care for that home so that you have a home for yourself. And we just wanna provide the tools for you to build it yourself.

Sabrina Duong (32:22)
A great analogy. And again, like you said, you know, it's knowing that you're worse than the investment yourself. Thanks so much, Stephanie, for sharing about DBT and the great introduction. I know we could probably have several episodes and talking about the modality but I appreciated learning so much from you today and look forward to having you on again.

Stephanie Fennell (32:24)
Yeah. Thanks for having me, Sabrina.