(AKA: What To Do If You Can't Access Therapy)

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About

This is a peer-created (non-professional) resource to supplement a professional Dialectical Behavior Therapy (DBT) program or to provide information to someone trying to access professional DBT therapy. It is not a replacement for professional DBT (or any other) therapy. It also includes references to several other therapies and clinical psychology concepts.

DBT is a type of therapy that works well for many disorders, but it was originally designed for Borderline Personality Disorder (BPD), which had no proven treatment at the time. It was created by Dr. Marsha Linehan, a licensed psychologist who had BPD herself. Dr. Linehan found relief from combining Zen Buddhism and Cognitive-Behavioral Therapy (CBT). DBT is the result of her merging the mindfulness practices of Zen Buddhism with the modern psychology concepts of CBT. Professional DBT therapy has been shown to help with many disorders, but it takes a long time for a professional to learn and become certified in. This means DBT can be hard to access for people living in rural areas or those who are struggling financially.

Who am I? No one really, but for background I'm a licensed health professional with my own history of mental illness and a strong family history of mental illness. Which license I hold specifically doesn't matter much since it's not one of the big or important ones, and I'm doing this mostly from a personal perspective anyway. Most of my personal experience is with DBT, and that's what I use with patients, so that's the main focus of this notebook, but I'm also including other therapies I have found helpful. I'm giving you all of this under the assumption that you either can't afford better resources or need help finding mental health resources, which I'm also happy to help with.

Accessing Formal Therapy Resources

Finding a Therapist
Try to commit to calling, emailing, or otherwise messaging a therapist each day until you've got an actual appointment. In the future I may write something about what the various qualifications are specifically, but for now, I'm assuming any therapist you can find will be better than nothing.

• If you have health insurance, their website or phone lines may have a directory of covered providers.
• Psychology Today has a general therapist search option with lots of filters including what insurance they take/if they do sliding-scale, but also specializing in problems they treat.
• If you want to try to get formal DBT specifically this is the Linehan Institute Listing of DBT Certified Therapists and Programs (They can be hard to find, like I said, so if you don't absolutely need DBT specifically, it may be easier to find a different type of therapist).
• There are a lot of services like BetterHelp that work kind of like doordash and the quality is generally similarly inconsistent but I'm trying to give you as many options as possible. For more options I would just google "Online therapy" and see what pops up. I might try to make a list of which ones seem more or less trustworthy at some point.
• You can also search for therapists on services like google maps, but then you have to do all of the vetting yourself. And you do need to vet the person you're about to trust with your deepest darkest secrets.

Finding a Workbook and Other Formal Resources:

• Workbook: Here is the official, up-to-date published version from the Linehan Institute. If you can't afford that, here (external) and here (external) are some older/out-of-date PDF versions.
• There is an official Online Course
• There are plenty of local and online mental health resources. I encourage you to use a discerning eye when deciding how trustworthy things are.

Finding Support Groups: These options are often free, sometimes paid, but almost always cheaper than individual therapy. It might seem like it would be depressing or embarrassing, and while it depends on the group, 99% of support groups I've been to were the most genuine people I've had the pleasure of meeting. Anyway, I'm putting the free stuff up front.

• Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Alanon, etc.
  • Pros: They are basically everywhere and basically always free. If you need somewhere to go almost any time, day or night, where people kind of understand what you're going through, these groups are available. You can usually just google meetings in your area. There are also many spinoffs for every possible issue, from gambling to codependency. For discretion, AA meetings are often listed on public noticeboards as "Friends of Bill" meetings, referring to the founder.
  • Cons: They can be kind of preachy, and I mean literally. While individual groups vary a lot, AA is founded on Christian philosophy. If you're okay with that, great, but if you have serious religious trauma, you might want to consider other options. Also, if your problem is narcotics specifically, try to avoid NA meetings where dealers might go to find buyers.
• National Alliance on Mental Illness (NAMI)
  • Pros: Very open and generalized, "Come as you are." It's for everybody, including people with any kind of mental illness as well as their friends, family, and other supporters.
  • Cons: Not as widely available as AA.
• Self-Management and Recovery Training (SMART)
  • Pros: A modern-therapy approach to substance abuse groups, using mostly behavioral therapy concepts. Very similar to DBT but better designed for a group-only format (DBT is designed to be done as both group and individual).
  • Cons: Can be hard to find meetings, and they're not always free.
• Wellness Recovery Action Planning (WRAP)
  • Pros: Really helpful for people with long-term mental illness. It helps you think deeply about your symptoms, what worsens or improves them, and what you need to do to plan for them.
  • Cons: Groups are almost always part of a larger paid program (like at a rehab or crisis stabilization facility) or otherwise paid (but I've got you on the free stuff, don't worry! Wellness Recovery Action Planning).
• Dialectal Behavior Therapy (DBT) Skills Groups
  • Pros: Excellent therapy with a huge amount of positive evidence even in some of the most difficult-to-treat disorders. Skills that blend modern psychology, medicine, traditional spiritual practices, and ways to conserve and target energy to combat injustice.
  • Cons: Almost always costs money, and the full tested strength involves an integrated group, individual, and phone-coaching approach that many programs don't fully implement.

Start Recording Your Mood and Behavior Daily

A big part of DBT is something called a "diary card," which is a daily log of moods and emotions in relation to the person's own behaviors as well as environmental conditions. There is usually a combination of numeric ratings (x number of times, 0-10 scales, etc) and brief qualitative / free text entries to provide details about the events of the day. Traditionally a single sheet of a diary card covers a 7-day week so that it can be reviewed in a weekly individual therapy appointment. It allows for a sort of "meta-mindfulness" where you become more aware of how your overall environment and activities affect your internal mood and vice-versa.

• [[Diary Card - UWash.pdf]] | External Link
• [[Diary Card - Beaches Therapy.pdf]] | External Link
• Diary Card - Note Template - to fill in if you're viewing this in an app that allows editing.
  These two apps have functions to track items very similar to a diary card:
• Daylio
• Moodpress

You could also write / journal, and many visual artists will make both 2d and 3d pieces depicting mood or environmental conditions over time. I've seen paintings of a year where green is a good mood day, red is a bad mood day, and a rusty-muddy color for neutral. I've seen knitted blankets where each row symbolizes a day or year. There's all kinds of options if you want to go more or less traditional with this, but the core concept is that you need to start recording your moods and behaviors. Getting back in touch with your body and emotions is going to be a key part of recovery and wellness. You may even find you keep this up in some form even after you've completed therapy.

Start going through the DBT Modules / Core Skills

Different programs have different numbers of or names for the sub-skills within each of these, but the four main modules or core skills are always the same. I've made a note for each one with the sub-skills I learned as completable checkboxes, but ultimately just do whatever works best for you.

Each week you choose a skill or set of skills from one of the modules / core skills, of which there are 4. You usually spend more than one week on each core skill learning multiple smaller sub-skills each week. Because mindfulness is the most important module, it's meant to be done in it's entirety first, but It's also meant to be repeated for at least one week between each of the other modules / core skills.

If you are in a particularly turbulent time in your life and need immediate help getting your head back above water, you could do Distress Tolerance first, but I would recommend at least taking one week to do Cheat Day Mindfulness first.

• Mindfulness is the hippie Buddhist monk shit and unfortunately also the most important module in DBT and one of the hardest to master. It can be hard for beginners, so if you’re having a lot of trouble, watch one of the meditation videos the first week then skip to distress tolerance.
• Distress Tolerance are the emergency skills. These skills are for when you are panicking or on the verge of doing something that you really shouldn't. They're the "rescue inhaler" or "epi-pen" of the psych world. You have to be careful not to over-use them! Just like rescue medications, rescue skills can lose effectiveness and start having weird side effects if you're using them too much or when you shouldn't be.
• Emotion Regulation is a set of good every day habits to help you live your best life. Distress tolerance is to get you out of a bad situation, but with emotion regulation, you focus on not getting into trouble to begin with.
• Interpersonal Effectiveness is how to manipulate people correctly. That's not even a joke; one of the core concepts of DBT is that the problem is NOT that the person is manipulative. In fact, the issue is usually that they're not manipulative enough! Properly manipulative people don't get caught and wind up in psych wards and therapy. Properly manipulative people are CEOs and Politicians. Here's how to properly manipulate people.