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Dialectical Behaviour Therapy and Art Psychotherapy for Mental Health with Megan Shiell

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Dialectical Behaviour Therapy and Art Psychotherapy for Mental Health with Megan Shiell

Borderline Personality Disorder (BPD) is often a poorly understood, stigmatised disorder and more common than you think, with between 1-3% of the population suffering a breakdown at some stage.

BPD can encompass feelings of depression, hopelessness, obsessive behaviors, self harm, suicide, substance abuse and unstable relationships. Dialectical behaviour therapy (DBT) is the new psychotherapy of choice in Australia for BPD.

Today we're talking to Megan Shiell, an experienced DBT and Art Psychotherapy clinician and educator about how she combines DBT and art to help those with BPD and other mental illnesses.

Megan takes us through some of the strategies in DBT that assist patients, through a mindfulness-style approach, to recognise and redirect their behaviours before they become an issue. She also shares her passion for educating both clients and health care professionals through affordable online programs she's developed.

Covered in this episode

[00:33] Introducing Megan Shiell
[03:54] What is art psychotherapy?
[06:56] What is dialectical behaviour therapy (DBT)?
[09:19] Understanding borderline personality disorder
[15:41] Selecting the right therapy
[20:26] Public vs Private: Accessing care in Australia
[23:06] DBT vs Cognitive Behaviour Therapy
[26:38] Areas of care where DBT might be relevant?
[30:20] Education and Training resources
[33:37] Distress tolerance skills: TIPP skills
[37:02] Accessing DBT training
[40:14] The use of art for healing

   


Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us on the line today is Megan Shiell. Megan is a registered art psychotherapist and a trainer and consultant in dialectical behaviour therapy, DBT. Joining these two approaches, Megan treats clients with emotional regulation problems and conducts endorsed trainings for other healthcare professionals and clients. 

Welcome to FX Medicine, Megan, how are you? 

Megan: I'm well. Thank you for having me. 

Andrew: Megan, for our listeners, can you take us through a little bit of your history. How did you first become an art psychotherapist? And indeed, when did you learn about dialectical behaviour therapy? 

Megan: Okay, well my first...I've been doing art for years, you know? It really is something to enjoy and also as a process to kind of supervise myself as a person, right through childhood, motherhood, relationships, I've always made art. And I've always found the value of reflecting on art as giving me a bit of a message. So that's sort of been in my background since I was little. 

Andrew: Yep. 

Megan: And when I got to, you know, most of my life working life was spent in the corporate world being, you know, a managerial and secretarial type executive assistant roles where I had to, you know, look after other people all the time. And people said to me, "Gee you're a good listener," and I sort of thought, ooh, that's nice. 

I'd always had this feeling of I like listening and, as you know, I like talking, so I put the two together and sort of...you know, having a little bit of a light bulb moment when I turned 50. And my children were growing up and I googled art, and I googled therapy. And blow me down, I found a Master's of art therapy course. And not easy to find in Australia, it's only available in about four universities. And I thought to myself, I've got Buckley’s of getting into this having left school at year 10. 

But as a mature student, and having done quite a lot of charity work, and also a lot of art-making and art studies, I applied. And luckily enough the wonderful people at the University of Western Sydney, especially the coordinator of the course, Jill Westwood who now runs the UK course, invited me for the interview process, which was horrendous. You had to take… I think it's a whole portfolio of all your artwork over the years.

Andrew: Yeah. 

Megan: To prove that you actually believe in what you're doing. 

Andrew: Yeah. 

Megan: And it was a five-hour interview process and that included writing passages of work. And I got in. I was more surprised than anyone, and five years later, 55, I qualified.

Andrew: Well done.

Megan: So I'm a very, very, late, late learner.

Andrew: Yeah. And as a registered art psychotherapist, how did you first come across DBT? Well, in fact, no, you know what? Before that, tell us a little bit about art psychotherapy.

Megan: Yeah. Art psychotherapy has got a long history. I mean we've got history of people making art, you know, right back through the centuries. But as a profession, it's been around since 1940’s. It was used by psychiatry after the Second World War, or during the Second World War to help people with symptoms of shellshock. They couldn't speak, so photographs and making art was a way of them communicating with their doctors on how they were feeling. 

Andrew: Wow. 

Megan: So this was kind of the beginning, yeah. And so it became an authentic, shall we say, profession of an art psychotherapist in the late 1940s both in America and in the U.K. 

Andrew: Right. 

Megan: So it's based on psychological theories, and it's a very difficult course to do. It encompasses two years full-time, Master's degree. And within that time, you have to do 750 clinical hours in psychiatric-related institutions. 

Andrew: Right. 

Megan: So you have to do a lot of supervision on your own work. And it is recommended that you must do your own personal therapy. So you don't take your self into the room with...

Andrew: Your baggage. 

Megan: Yeah. So it's a very serious profession. And unless you've done the two years Master's degree, you really aren't qualified to work in mental health. So that would be my message. 

There's an awful lot of people who are trained in psychology, counselling, social work, OT, and rightly so they use creativity, fantastic. But to just say I'm adding a bit of art therapy to my practice is a little bit insulting.

Andrew: Right. Is there a difference between art psychotherapy and art therapy?

Megan: No, just the words.

Andrew: Right, exactly the same thing. 

Megan: Yep.

Andrew: So for instance, we're going to be mainly talking about this in the psychiatric arena if you like?

Megan: Yep. 

Andrew: But the same principles could be applied to cancer patients and things like that as well. 

Megan: Oh, absolutely. Yeah, there's a lot of research around with art psychotherapy and cancer patients. There’s a wonderful journal called ANZJAT, Australian and New Zealand Art Therapy Journal, and there's British journals and American journals where the work that's been done across the spectrum of ages and illnesses is astonishing. 

Andrew: Wow. 

Megan: From children to the age with dementia, art therapy is a wonderful intervention.

Andrew: As a registered art psychotherapist, how did you first come across DBT, ‘dialectical behaviour therapy?’

Megan: Ahh, yes. Well, I had to do a placement in a private hospital in Sydney, and they already had a dialectical behaviour therapy, or DBT I'll call it…

Andrew: Yes. 

Megan: ..Program going. Where they asked me as an art therapist if I'd design a short program like an 8 to 10-week program where patients could do the verbal learning in the morning of dialectical behaviour therapy, its skills and strategies, and could I design and artwork to go with that learning for that day? And so they had two experiences, verbal and nonverbal, and that's where I first began. 

Andrew: And exactly what is DBT? Because like I'm aware of CBT?

Megan: Yes, yes, yes. 

Andrew: That's been bandied around for a long time. I constantly get whipped by a doctor friend of mine saying, "You need to talk about mindfulness." But what is DBT and how does it work to help clients suffering from emotional dysregulation?

Megan: Well, originally...I guess I've got to go to why DBT was first designed?

Andrew: Yeah. 

Megan: And that was first designed for patients who presented with what was called borderline personality disorder. 

Andrew: Right. 

Megan: So that is a label that was given to people who had very great difficulty with emotion regulation. And the label was given to that client grouping around 1938 by psychiatrists. They called it ‘borderline’ because it was set between psychosis and neurosis. And so it was on the border of a lot of different disorders. What we would like to see changed is the label because it has stigma attached to it now as being...

Andrew: Yeah, it seems really nasty like you're bad, you know.

Megan: Yeah, it's nasty. And you know, people get tagged with "Okay, she's BPD,” so let's just treat her with behavioural problems. And in fact, borderline personality disorder is an extremely serious mental illness.

Andrew: With borderline personality disorder, can you give us a definition? Because like I remember this thing floating around myself about people who were detached because of stressors, and I seem to recall...forgive me, forgive my dim memory, but I seem to recall this, how some patients could feel either being feeling like an "Alice in Wonderland," like overly large or overly small. Is that part of borderline personality disorder?

Megan: Well, some of the symptoms can present like that. But usually that's a defence mechanism because they don't know how to cope, or they're unskilled in interpersonal effectiveness. So they can come across larger than life, or they can come across as completely introverted. 

Andrew: Right. 

Megan: It depends on their mood, it depends on the stressors around their lives. 

Andrew: Yeah. 

Megan: But the DSM-5 has got BPD with several criteria, and a psychiatrist or psychologist could diagnose someone with BPD if they had five or more of these particular criteria. 

So one is an anxious preoccupation with being abandoned and rejected. So in the back of their minds, all the time, is someone's going to let me down. Someone's going to stop working with me, someone's not going to love me forever. So that leads them to have some real intense relationships and they kind of perceive other people as bad too. And they can love you or hate you. You know, as a therapist, they can be, "Oh, I am running to everything you're doing with me, it's fantastic," and, "No thanks," within 10 minutes of the session. 

Andrew: Oh, right. 

Megan: Yeah, so I mean, it depends entirely on where they're coming from on the day with their stressor as to, you know, how they will portray their mood. 

Andrew: Right. 

Megan: So they kind of think...I've had a lot of BPD people over the years that I've treated who say something's wrong with me I am actually bad. My self is bad. And that has this kind of inner feeling of negativity. Their emotions are so out of control that the only way they can keep themselves stable is to use self-harm.

Sometimes they feel like their brain is so busy, their thoughts are so rampant that they can't control their brain, so they can use substances to calm themselves down. Sometimes a strategy can be, "I think I need to be admitted to hospital. So if I attempt suicide, someone will look after me because I don't know how to look after myself." 

Andrew: Right. 

Megan: So that's why there's a revolving door patient.

Andrew: That seems to be like a little bit of a tag in there with sort of, you know, flight of ideas, so the mania sort of?

Megan: Well, it is, but it doesn't last like bipolar. 

Andrew: Right. 

Megan: So they have this chronic feeling of emptiness inside, chronic negative emotion. 

Andrew: Right. 

Megan: And they have sudden shifts from anxiety to depression, sudden shifts. 

Andrew: Yep. 

Megan: They don't have manic episodes that last for two days. So that's the difference in diagnosis, and unfortunately, a lot of people with BPD are being misdiagnosed as having bipolar. Because then the medical profession can medicate them with mood stabilisers and antidepressants. 

And in actual fact, the evidence says that anybody with borderline personality disorder should not be having medication as their first line of treatment.

Andrew: Right, so here is another one of those...

Megan: Hello!

Andrew: How often does this happen?

Megan: I know.

Andrew: Overmedicated and underdiagnosed? 

Megan: I know, and these poor guys, you know, their lives are unbearable and they're not treated with respect. They've been given medication that puts on weight, that makes them tired and they can't think. It's actually really disrespectful the way this client group is being treated.

Andrew: You know, so often we hear in psychiatry...and I guess the issue with psychiatry is that you've got a group of disorders that are still, in the 21st century, diagnosed by clinical expertise. 

Megan: Yeah, there some research done by a guy at the University of Toronto I think it is? Dr Anthony Ruocco, he's a Professor of Psychology at the University of Toronto. And he was trying to work out if there's a neural basis for the symptoms of emotional dysregulation. Because then you could diagnose and you could treat appropriately.

Andrew: Yes, absolutely.

Megan: And so what he's doing is doing some tests on the brain. And he's worked out, from a few samples that he's done and he's continuing to look into this, that the impulse control part of the brain, the frontal lobe, doesn't work in people with BPD.

Andrew: Right. 

Megan: It’s shut off. Completely shut off. And so they don't know how to put the brakes on. 

Andrew: Right. 

Megan: So can relate to self-harming behaviour, suicide, relationship breakdown, violent outbursts, all of that sort of thing.

He also said that the best part of the brain where there is the negative thought control part, is all the on high alert all the time. So their self-critic is like their backpack. 

Andrew: Right. 

Megan: So he thinks in time we'll be able to diagnose this disorder through brain scans. 

Andrew: Yeah. I was just thinking about this. Swinburne Uni's got some awesome equipment where they can look at moving things. If you were talking about personality shifts that happen very rapidly they've got stuff that can scan at real-time, it's just amazing stuff.

Megan: It's amazing yeah. 

Andrew: That's...

Megan: He's talking about a magnetic seizure therapy that may work to kick that frontal lobe back into operation, over time, but very early days in the research. 

Andrew: Right. What about things like art psychotherapy combined with DBT or art psychotherapy instead of, do you choose? Do you individualise it?

Megan: No, me myself, my passion is joining the two together. Because the evidence-based treatment for anybody with borderline personality disorder is dialectical behaviour therapy, and that's at adult level. And that's been researched and documented since 1970. So it's been around a long time.

And I believe that this client group, as do many other people, that they need skills and strategies to practice and to use every day of their lives to hold themselves in some sort of form of stability. And that's what DBT does. So DBT therapy is quite a huge therapy, and...would you like it if I went into what it contains? 

Andrew: Absolutely, please. 

Megan: Okay, so there's five arms to dialectical behaviour therapy. It's client-focused, so everything is done with the client in mind. The first arm is to attend a skills training group once a week for two-and-a-half hours, not a day program, and that's happening in all private hospitals.

Andrew: Got you.

Megan: Because private health insurance wants five hours of a person being present. 

Andrew: Right. 

Megan: So BPD people, that's too long, two-and-a-half hours is it. For adolescents with BPD traits, two hours is long enough. 

Andrew: Right. 

Megan: Then you have an individual therapist you see once a week who is a specialist in dialectical behaviour therapy. Then you have phone coaching, which in America is 24 hours a day for crisis management. Then you have a consult team where all the therapists come together once a week or once a fortnight to work out how they can help each other treat this client group.

And then you have the psychiatrist who is present. And sometimes you have the hospital manager or the centre manager present as well. So that everybody is holding this therapy and that client safely for a whole year.

Andrew: Yeah, and so how rapid can the changes be when people are instituting DBT?

Megan: After a year the American stats are 76% of people who suffer from borderline personality disorder completely recover. 

Andrew: Wow. 

Megan: Now, this was considered the wastebasket diagnosis. And the evidence says that you can completely recover from this disorder. Sure you'll have relapses…

Andrew: Yeah. 

Megan: Sure you'll have stressful times, and losses, and job changes and you'll go back into some of the symptoms, but never for as long as you do when you present in early days. 

Andrew: Right. And I guess, you know, once they've got the skill set, I wouldn't say necessarily riding a bike, but they know that they know what to do. 

Megan: They know what to do.

Andrew: They know where to seek help, they know that it's available, they know that it works. 

Megan: Yep, yep. 

Andrew: So there's an air of confidence. It's kind of like, you know, getting on a treadmill the second time, it's much easier, your heart rate goes down. 

Megan: Yes, exactly. And they have to build...that's why it takes a year. They have to build the confidence. They do the program twice. There's four modules in the program. One is called Mindfulness, you were talking about mindfulness before. 

Andrew: Yep. 

Megan: Mindfulness is everything in DBT.

Andrew: Right. 

Megan: Because if you can't be mindful to your urge to act, you can't bring in a skill. 

Andrew: Got you. 

Megan: So mindfulness is everything. Mindfulness to your emotions, mindfulness to your triggers, mindfulness to the day ahead, all sorts of things. 

So that's taught for, you know, totally for about six to eight weeks. In six months. Then distress tolerance is taught for about seven weeks. With fabulous skills. And the next...a lot of skills is emotion regulation, so understanding your emotion and how to regulate them, and how to keep yourself healthy.

And the last skills are interpersonal effectiveness. Because people with emotion regulation problems have a lot of trouble in communicating with other people. They usually misunderstand what they're hearing, or other people misunderstand what they’re saying. 

Andrew: Right. 

Megan: So that gets them into a lot of trouble in patient's wards or emergency departments. 

Andrew: You mentioned private health insurance previously. Now obviously, this is for the Australian healthcare landscape, and our listeners overseas will have to investigate their own landscape. But what is the lay of the land with private health insurance in Australia? And indeed, do you have to have a diagnosis to be able to access private health insurance for DBT? Or can it be a healthy thing that one could implement? 

Megan: Yeah. Well, it depends on how up to date the hospital is, to be honest.

Andrew: Right. 

Megan: And the practitioners in there. The latest research from Marsha Linehan who designed the whole program of dialectical behaviour therapy now says it can be for everybody. It's a skill set to help anybody who can improve their emotion regulation. 

So in her 2015 second edition manual, she's got heaps of random controlled trials, heaps of evidence to suggest that it's going to be good for depression, anxiety, eating disorders, drug and alcohol substance abuse, all sorts of things. 

So it is starting to feed through into private health hospitals. And the diagnosis doesn't have to be borderline personality disorder anymore.

Andrew: To access private health insurance, really?

Megan: Yeah. 

Andrew: So obviously Australian listeners, I would say check it out with your own health fund. 

Megan: Yeah, exactly. 

Andrew: Yeah. 

Megan: Yeah. Because they're not going to call it the DBT program. They're going to call it maybe a DBT informed program. 

Andrew: Right. 

Megan: Because in actual fact, even though they are saying it is the research model, very rarely in Australia can you find the research model. 

You may get it in public hospitals with this staff that can do 24-hour phone coaching. Most of the public hospitals that are offering DBT are only doing the skills program. How many people who are chaotically, emotionally dysregulated can afford private health insurance?

Andrew: True, very true.

Megan: You see. And what Marsha says is this was originally an outpatient treatment. So we don't want them in hospital too long, we want them to learn how to live outside hospital. 

So that gives the hospitals in this country oh, somebody said if you've got the BPD, you shouldn't be in hospital for more than 48 hours. So you can't stay, there's no mention of where you go afterwards.

Andrew: No. That's kind of like where's the postnatal program? But anyway.

Megan: Oh yeah, Mmmmm.

Andrew: What are the real and crucial differences between DBT and cognitive behaviour therapy (CBT)?

Megan: A lot of the DBT skills are based on cognitive behaviour therapy, they’re just taught in a different way.

Andrew: Right. 

Megan: The style of how you teach the skills in DBT is using validation as often as you can. Using encouragement, genuineness, but most importantly dialectics. So I'm just going to describe...

Andrew: Yeah, we need to.

Megan: ...dialectics quickly. It's just a funny old word. 

Quite often people who are emotionally dysregulated get themselves stuck in fixed positions, black and white thinking. You know, "If I'm going to late today that means I do not go to see the psychiatrist because I never go anywhere when I'm late." 

So as a DBT therapist, I'd say to the patient, "Yes, that's true, you are late, you woke up late, you know, you had a bad night the night before, things didn't go really well." So I'm validating. "And it's really hard for you to get moving fast, and that is true. And it's also true that you want to cancel your appointment because the last thing you want to do is go and have an appointment when you're rushed. So I get that even though these two things are opposite, they're actually both true to you.”

Andrew: Yep. 

Megan: “So what I want to suggest to you is, how do we get you into the middle path?" This is dialectics.

Andrew: Yep. 

Megan: "Given that both of those things are true, how do we get you into, what skills could I use? What people could I call on? What strategies can I use for phone calls, etc, just so that I can get my prescription today?" 

Andrew: Right. 

Megan: So we're problem-solving, that's all it is. We're problem-solving by getting them off the stuck positions they are in, their polarization. Then that's a simple as it is. And they've got to use dialectics 24 hours a day.

Andrew: Because we make these, you know, thousands of choices all throughout the day and they're stuck in this polar thing, is that what happens?

Megan: Yeah, yeah.

Andrew: So is it really teaching people to be more fluid? So it's almost like brain derived neurotrophic factor helping with brain plasticity, it's really re-engaging plasticity in their choices.

Megan: Exactly. It is, and it's not about thinking. So CBT concentrates on the thoughts that a person has and their belief systems that they might have grown up with, which affects them emotionally and gets them into these stuck positions. Dialectical behaviour therapy focuses on the urges to act, the emotion.

Andrew: Right. 

Megan: Doesn't focus on the thought. It says to a patient, no matter what you're thinking your brain is just doing its job. You know, it's got thoughts coming in, thoughts going out good ones, bad ones, worry ones, happy ones.

It's just let them go through your brain, in and out, in and out. But what happens is when you get negative thoughts over and over again, you'll get a chemical reaction, your cortisol hormone will get involved, adrenaline, that will flow down your body to give you an urge to act, and you will have an emotion. And that emotion drives your behaviour. 

So it's all about slowing down enough in this crazy world of ours to become more mindful that I have been triggered by something, and I need to use a skill. 

Andrew: Megan, we have a massive issue with assault in Australia.

Megan: Yep. 

Andrew: Based on relationships. 

Megan: Yes. 

Andrew: And A) could it be useful and then practically, because the...and it is usually males, because the males who usually cause the assault, they have their framework which they're stuck in. Could this be something that the legal system could force upon perpetrators of assault? 

Megan: Yes. Absolutely, it should, it is in correctional centres all through the UK. We're just a bit slow. It is perfect, you've got a captive audience.

Andrew: Wowee. 

Megan: But you know, the actual treatment has to be...it has to be much broader than just a skills training group. 

Andrew: Yeah. 

Megan: Yeah. And that's really what we're talking about when you look at what's called the guidelines that, mind you, were designed in 2012, and I don't know anybody...I've trained 3,000 people in the last 10 years, and no one has read this document, out of that cohort that I've trained. 

It's a document that is prepared by the government that gives guidelines on how to treat people with borderline personality disorder. It's the National Health and Medical Research Council, "Clinical Practice Guidelines for the Management of Borderline Personality Disorder.

It gives a complete outline on how you treat them in emergency. You should be respectful, show empathy, consistent, reliable, listen, pay attention, validate, have a non-judgmental stance, stay calm, communicate clearly, and make sure you refer on to a cohesive system of care. 

Andrew: Wow. 

Megan: None of that happens. 

Andrew: None of that happens.

Megan: And this book is fabulous, it's got all of the recommendations for families, how families can help. It recommends that in Australia, we should adopt an idea called ‘good clinical care.’ Because you're not going to adopt the full DBT.

Andrew: Yeah. 

Megan: You're going to muck-around around the edges with no phone coaching, no crisis management. So good clinical care would be something similar to what Project Air is offering. Wonderful organisation in New South Wales which offers...and it's now being funded by the government as of July for another $5 million, to help more community health areas. And what it does, it's like the organisation that comes in and helps people in crisis. 

Andrew: Right. 

Megan: So someone who's self-harmed or tried to commit suicide is given a gold coin, and if that person's got a gold coin, they show it a triage emergency, or a gold card. And then the people at emergency don't have to ask them their history, they just look at all the history online.

Andrew: On the card, right.

Megan: Yeah, so they don't have to put them through the traumatic experience of, "So tell me why you did this, tell me where's the trauma?"

Andrew: Right, right. 

Megan: And their system, Project Air, is to immediately give that patient three or four very fast appointments.

Andrew: Right. 

Megan: So they can solve their crises quickly, instead of getting more concerned and more chaotic. So something's happening in Australia, but it's only piecemeal, really. 

Andrew: Yeah. So you said you've trained 3,000 people? 

Megan: Yeah. 

Andrew: I'm going to imagine that they're mostly healthcare professionals. 

Megan: Yeah, social workers.

Andrew: I can see that what needs to happen is that you need to be training about 5,000, 6,000 people and they need to be people like prison wardens and teachers as well. 

Megan: Oh, gosh yeah. Well, what I've been, you know, really...I train in each state of Australia and in New Zealand, in Auckland, every year, but I can't keep doing that at that pace. And also I've contract...probably five to six is my limit to different regional organisations because I love training NGOs who can actually get this thing off the ground. I trained a whole group in Rockhampton, for Anglicare, and Gladstone they're actually running the proper DBT program in Anglicare. Because they're the kind of NGOs who end up trying to look after these people. 

Andrew: Yeah, got you. 

Megan: Because the medical profession isn't.

Andrew: Yeah. Now you're talking about you can't keep doing this because there's only so many times we can clone you. But, I think you and I were talking about that you've developed an online program

Megan: So yeah, I have. I got so frustrated with nobody...or half the people I ask when I'm doing the training is, "Have you ever heard of DBT? Have you ever done any training?" And look, you know, 9 out of 10, "No, I don't know what it is. I've had a look at the book and read that. And I just use the book and teach from that, never been trained."

Andrew: Right. 

Megan: Which horrifies me. I mean the authentic training for DBT is from Marsha's people herself who come out here. That training is, you can only...well, it used to be when I did it back in 2005, no, 2008 I did it. You have to do it as a team because it's a team approach. 

Andrew: Yeah. 

Megan: So I worked in a hospital where we got everybody together, formed a team. You went down and did a week full-time, 8:00 to 5:00, where you learned all about DBT. You had to come back, set up your whole program in the hospital with all the arms. And then go back six months later with all your evidence and data and explain how your team was doing DBT and they pulled your team apart for a whole week. And it was really nasty.

Andrew: Well, I can imagine though the data and data-based validation, like this would be critical in figuring out where it works, and indeed, where its shortfalls might lie and where you can improve it. 

Megan: Yeah, we're really short on it. There's a big cry for more evidence. We've got Dr Andrew Chanen, who's done a lot of work in Orygen. And we've got Professor Josephine Beatson and Spectrum in Melbourne, they're doing a lot of work in trying to get more information out to the public. 

And really trying to emphasise that this client group or anybody with emotional regulation needs a community around them to look after them. 

Andrew: Yeah. 

Megan: So the GP should be talking to the psychiatrist, who should be talking to the DBT therapist, who should be talking to the skills trainer. So that everybody's holding this patient, and none of that is happening. So no one gets really well. 

Andrew: So what have you noticed though, when people do effectively use DBT, they go through the whole program, what have you seen out the other end? What are the differences before and after?

Megan: Oh, it's astonishing and that's why I love it. 

It can be done one-on-one, in one-on-one therapy as well, and I'll talk through one of my patients at the end here when I'll talk about that picture of the mask. But in a group setting what you get is people come in with no hope, also feeling really angry that no one has told them that they could have learned these skills a long time ago.

Andrew: Yeah. 

Megan: And so when you get through all of that and teach them some of the quick-fire skills of DBT, they start to really get focused and practice, practice, practice these skills. And they're really simple and strategic. 

So I'll just tell you one skill, it's called the TIPP skill, and this will be great for, you know, violence, domestic violence. 

Andrew: Yep. 

Megan: If you start to learn how to be mindful of your emotions, and your urges to act, you know something's going wrong in your body. Like your hands are shaking or your throat is tight, or your heads hurting. Your physical body saying, uh-oh, something is going on.

Andrew: Yep, yep. 

Megan: So immediately, you could use the TIPP skill. The TIPP skill is getting your face cold. It's called the dive reflex. It's putting an ice pack or really cold water from your eyelids right down to your neck. Really cold. You know how you feel when you jump in the ocean and it goes, oh...?

Andrew: Yeah.

Megan: That's what you want to do. Now that's the quickest way to change the chemical reaction in the brain. 

Andrew: Right. 

Megan: It's all you do. It’s all you do. When you get really angry, go and get your face wet. My grandma said that to me, "Go and wash your face." So that's all it is. Get your temperature down. 

Then the I in TIPP is intense exercise. We want to change the chemistry. Because we can't problem solve, and we can't sort out our problem, so we have to run around the block five times, or walk fast, or do weights. The first P is for pace breathing. Use your own body to calm yourself down. So it's five breaths, in hold for two, eight breaths out. You're actually using everything that you've got, which costs you nothing, to lower your emotion problem.

And the last one is paired muscle relaxation. No one has to see you doing it. You're just tightening two hands and relaxing two hands. So you're using that all the way through your body. So that TIPP skill is the quickest and fastest skill I teach patients. 

Andrew: Wow. 

Megan: Especially if I'm on the phone to them.

Andrew: Yeah. 

Megan: And they've got an urge to drink or self-harm… “Rightey-Oh, go and use the TIPP skill right now. Text me back."

Andrew: We're definitely going to be putting this stuff up on the FX Medicine website. But I also want to make sure that people do...they learn these sort of skills properly. So they need to be, you know, educated. But you know, hey, even in a certain sort of emergency situation, I guess that sort of worthwhile knowing the TIPP principles.

Megan: Yeah, absolutely. That's just one of them. There's so many quick fast skills that you can use without having to do any cognitive work. 

Andrew: Yeah, what about caveats? Now, we've mentioned the caveat of making sure that you're properly educated about this stuff. And that's because that goes into the responsibility of caring for clients in a proper way. You wouldn't want to be a half a naturopath, you wouldn't want to be six months into medicine and say, "I can put a shingle up." So you need to have appropriate training, that goes without saying. What other caveats though?

Megan: Yeah. Well, I think actually they should be introducing maybe two-day intensive trainings into social workers degrees, psychologist degrees, OTs degrees. So doing like a half a day of this is basically what it looks like. 

Andrew: Right. 

Megan: And so that's one way you could quickly speed it up with what to do with this client group instead of floundering around. The worst thing you can do is have two therapists behaving in a different way. So if you're running a skills training group, the facilitator might be really skilled up in DBT, and she knows how to hold the frame. She knows the discipline required to keep the conversation on the skills. 

And if, say, you had another therapist there who was into reflective listening or narrative therapy, you're going to split. I mean those clients are just going to love her and hate the other one. So it's really important that people don't just do this from the book. Go and get the training. 

Andrew: Where can we find out more, Megan?

Megan: You can go to the Australian BPD Foundation Limited, that's a voluntary web page where you can watch webinars all about this. You can go to Spectrum in Victoria and have a look at what they offer. You can go to Orygen in, I think it's in Victoria as well or maybe Sydney, where you can see what they do. You can go to Project Air online to have a look at what they're offering. 

Andrew: Yeah, yeah. 

Megan: So as far as DBT goes, there are trainings out there that they have to get and they're expensive. 

Andrew: Right. 

Megan: Marsha is now doing a lot of online training as she's getting older, I guess, and doesn't want to travel as much. So they're very expensive.

Mine, I've introduced online training on my web page at expressivetherapyclinic.com.au. And what I've done is tried to make a 10-session program. Because that's what Medicare will allow you to have. So I've designed a 10-session skills program for clients, and it's really cheap, $110 for 10 hours.

Andrew: Oh wow, this is awesome.

Megan: And they can go and they can learn it all by themselves, or they can take it to their practitioner and do it with them. 

Andrew: Yeah. 

Megan: And I've also designed to 10-session DBT skills training program for healthcare professionals, for professional development which is endorsed by most Australian organisations. 

Andrew: This is brilliant.

Megan: So I'm really hoping that anywhere around the world if people want to learn skills quickly, there's a very quick way of doing it.

Andrew: Now lastly, can you tell us a little bit more about the art psychotherapy? 

Megan: Yeah, definitely. So my passion has been to use art therapy or art psychotherapy alongside the skill. So once they learn a skill, I get them to create an object. And I can probably describe one of the skills and the object to you through that image, one of those images I've sent you. 

Andrew: Yep. 

Megan: Doing an image or an object lets them learn in a different way. Art therapy drills from your unconscious mind, you are in a mindful state when you're focusing on making. And when you make something, it's your own words, your own reflections that mean, for you, what that image means.

So it's like Winnicott calls a transitional object. The artwork is something outside of yourself, which is original, which has its own meaning for you, no one else. And it can help you understand what's going on whether it's directive art therapy on how to use a skill, or whether it's going to actually show you where you're stuck. 

Art therapy is a very good intervention for getting to the root of problems very quickly. So we talk through the image, and that's why it's not threatening, that's the value of art therapy. 

Andrew: Right. Megan Shiell, thank you so much for taking us through both art psychotherapy and dialectical behaviour therapy today, DBT. 

I mean, these are such critical skills that we all need to have in our armamentarium to help patients and people under extreme stress. I really thank you for taking us through these very important skill sets that we need to have today.

Megan: Okay, my pleasure.

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook.



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The information provided on FX Medicine is for educational and informational purposes only. The information provided on this site is not, nor is it intended to be, a substitute for professional advice or care. Please seek the advice of a qualified health care professional in the event something you have read here raises questions or concerns regarding your health.

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FX Medicine Podcast
FX Medicine is at the forefront of ensuring functional and integrative medicine gains the recognition it deserves and ultimately establishes itself as an integral part of standard medical practice. Hosted by Andrew Whitfield-Cook, our podcasts are designed to promote research and evidence-based therapeutic practises, acting as a progressive force for change and improvement in patient health and wellbeing.