Ep. 016 | Dialectical Behavior Therapy (DBT) in Music Therapy

Today, we chat with guest, Marissa Renalla, a board-certified music therapist with Seattle Children’s Hospital, as she shares about how she uses in DBT principles in her practice.

LEARN MORE

What is DBT? by G. Gleissner | Online Article

DBT Continuing Education for Music Therapists by Spiegel Academy | Website

TRANSCRIPT

Erica: Welcome, friends! You’re listening to The Feeling is Musical — as presented by the Snohomish County Music Project. My name is Erica Lee, and, in honor of national mental health month, this week we are talking about Dialectical Behavior Therapy, with board certified music therapist, Marissa Renella, as the final episode of our four part series all about various topics within the field of mental health care.

Marissa is a board certified music therapist and pediatric mental health specialist on the Psychiatry and Behavioral Medicine Unit at Seattle Children’s Hospital. Following her clinical internship at St. Elizabeth’s Psychiatric Hospital in Washington, DC, Marissa pursued her passion of integrating music therapy into standard psychiatric care. In her current work, she works collaboratively with mental health therapists, psychiatrists, nurses, and other healthcare professionals to provide music therapy that reinforces DBT skills, and helps patients understand the role that music plays in their lives.

[Podcast intro music plays]

Erica: Hi, Marissa, thank you for being on the podcast!

Marissa: Hi! Thanks for having me.

Erica: No problem. Okay, so, I’m excited to talk about DBT in music therapy today. Before we talk specifically about DBT, can you give us a brief overview of how did you get into the mental health field as a music therapist?

Marissa: Yeah, absolutely. So, during my internship at St. Elizabeth’s Hospital in Washington, DC, I really got to see how music therapy was very thoroughly integrated into psychiatric care. I worked with a lot of patients, um who only received like group music therapy services and individual services, and I found it to be very effective - I observed a lot of progress in these individuals’ lives. And, upon moving back to Washington, I really just wanted to see how we could kinda change the pace of things on the West coast, and see if that can’t be done in another setting. And so I had a friend who recommended that I start working at Seattle Children’s Hospital on the Psychiatry and Behavioral Medicine Unit - PBMU for short - and he was like, hey, you should come - get some psych experience you know, post internship, you know, so you can really, you know, learn more about what’s going on in, you know, acute crisis stabilization.

And so, I got a job as a pediatric mental health specialist, and - even in my interview, I was like, hey, I’m also a music therapist, and, ideally I would become our unit music therapist, because I think that music therapy can be a really effective modality of treatment for our patients. And, so from day one, the whole unit knew that I wanted to do this [chuckles]. And so, it was great to have a full year of advocacy with my co-workers, my managers, our unit director, clinical director, and also the other music therapists working at Seattle Children’s Hospital. And so, it took us a little over a year, and finally, we were able to find the funding for me to have a two-year therapeutic pilot study position, providing music therapy on only the Psychiatry and Behavioral Medicine Unit for 2 years - 2 days a week. And so, this was really great - the collaboration and innovation between everyone was awesome.

And so now, I am about - let’s see - a little over a quarter of the way through - and we’ve just done so much great work - and there’s so much potential. SO right now, I’m really focused on supporting the unit’s existing philosophy and scope of services, which is crisis stabilization and intense skill building in a very short amount of time. And so, a lot of the times, you know, we can translate our music goals into nonmusical goals, but the setting is - is a lot different - it’s like, I may only see these kids for 1 session - and we’re really kinda zooming in and focusing on what’s most important to keep them safe. And, our unit philosophy includes basic DBT skills and structure - and so, um the mental health therapists and the psychiatrists - the whole treatment team is already implementing DBT interventions and teaching the kids all these different skills, and so I quickly realized that my job and my role as a music therapist is I’m gonna support everything that we’re already doing - using music.

Erica: Totally. Okay, so - that’s super awesome. So let’s dive in a little bit about DBT specifically. For anybody that’s not familiar, can you give us an entry level overview of what is dialectical behavior therapy?

Marissa: Yeah, absolutely. So, we’ll start with the first letter - dialectical. Dialectical means, eseentially, that it’s a balance between 2 things, and that there’s always gonna be multiple options in our lives for everything that we do. But the main balance that we focus on in DBT is the balance between acceptance and change. And the overall goal is to create a fulfilling life that is worthwhile and you are engaging in things that you enjoy - activities, hobbies, etc - you have meaningful relationships. That’s the - that’s the overall goal and focus of DBT - is that balance, and then having a fulfilling and worthwhile life.

Erica: Mmm. And so, what are some of the major principles or concepts within DBT?

Marissa: Yeah, absolutely. So, the structure of DBT can look different, like logistically, depending on what facility you’re at, or if it’s inpatient or outpatient, so I’ll just focus on the 4 kinda skill groups that we focus on um on the PBMU. SO, we focus on emotion regulation, which, in my mind, is kind of like the hardest stuff. So, this is like when you’re digging deep, and you’re trying to learn how to not let your emotions control you - and you’re learning how to control your emotions step by step. Everything is really - it’s really hard, and that’s - this is more of like the change part - and you’re really just like breaking things down and just practicing and practicing. And it - emotion regu - learning emotion regulation can take a very very long time - especially when you’ve like experienced trauma - and the way that you react to your emotions, and the behavior that happens in result to your emotions is learned - and kind of engrained in your brain. Um, so this - I think - I mentioned this one first because, I think this is the hardest one —

Erica: Mmm —

Marissa: For our patients that I’ve seen - is like, you know, when you’re experiencing this emotion, it’s your mind, it’s your body - it’s changing your environment, you know, you may be interacting with people different - how do you control that. So that’s emotion regulation.

The second one is distress tolerance. And so, these are amazing skills to get you through those hard and intense moments and emotions in a safe way. So, essentially, if you were to kind of imagine like emotion regulation being like the main pathway, and then distress tolerance being like your breaks along the road. And so, distress tolerance is, you know, distraction skills, self-soothing, you know, relaxation - like, how are you taking care of yourself while you are working through these hard moments. And so, those are the like more skill and activity-based things that we can help our patients learn - of, you know, like learning how to play cards, or, you know, picking up just like a skill that can occupy your mind so that you can stay safe in the moment.

And another big part of DBT - and really, kinda one of the philosophical underpinnings of DBT, is that all of our conflict in our lives stems from how we interact with others - and our relationships. And so, you know, we’re - you - we’re usually having these strong emotions because of some conflict that we’re having in our lives with other people - whether it be parents, friends, partners, etc -you know, at school. So this interpersonal effectiveness piece of DBT really supports, you know, building those meaningful and healthy relationships. And so, you can learn about different ways of communication, and you know, how to talk to someone, and how to express your feelings to someone without causing more conflict. Yeah.

And then, the fourth skill group um is mindfulness. And so, this is a practice that I think really is a foundation for all of these skills - and for learning for all of these things. And it’s just being able to be present in the moment. And this skill includes your emotions, it includes your attention, and it’s really like being able to like zoom in, and pause everything else - and focus in the moment. And this is where the learning happens - this is where change happens. And so, these mindfulness skills, we practice constantly on the unit - you know, if we’re - even if we’re playing like a short game or, you know, just having a conversation - and practicing those distraction skills. So, mindfulness is kind of foundation for all that.

Erica: Mmm. So, within each of those categories, what are some music specific interventions that you do to address those?

Marissa: Yeah, absolutely. So - I’ll start with um distress tolerance and emotion regulation. And so - kind of as a basic - with every patient that I work with, I try to help them kind of take inventory of the music in their lives.

Erica: Mmm.

Marissa: So, you know, how are you using music in your lives - you know, how does music impact us, right? Does - do  you even believe that, right? Kind of assessing where they’re at - does music impact you - you know, when you listen to a song, do you - does it change your mood? Can it change your emotion? Do you feel anything in your body? Do you any thoughts coming up? Um, and then, you know, how do we use music to get through these hard moments? And so, one of the first things that I like to do with patients is helping them kinda work through a personal music inventory. And so, this includes, you know, identifying your reactions to music, identifying your preferences - just seeing what you like - what you don’t like. And then, we can kind of figure out what might be harmful, and what might be helpful, as far as listening to music. Because a lot of the kids that I work with - they’re all adolescents, you know, 9, 10, 11 years old - and they love music, and they have their favorite music, and they, you know, will listen to it all day every day on their iPod at home and - and even through school and everything. And I - I kinda  challenge them - it’s kinda that change piece, right. So, first, I’m accepting their music preferences, you know, even if it includes explicit language or anything like that - you know, like I try as, as best as I can, to express to them that I accept their music, and nothing is right or wrong. So there’s that acceptance piece.

And then, on the other side, I challenge them. And I’m like, hey, you do - like, let’s look at how this music could actually be harmful to you. And, you know, for example, um, there are artists that, you know, their express - in their music, they express a lot of their depression, anxiety, hopelessness, isolation - and that’s what they sing about. And we kind of can get stuck, listening to that music, because it can be validating, right? You listen to a song, and you’re like, gosh, this is exactly how I’m feeling - like, I feel so validated - I feel not alone. Which, you know, can be important - you know, especially kind of getting through those hard moments where you have that thought of I’m not alone, somebody else is experiencing this. But if we sit in that, then we’re not able to move out of those emotions and control that - those emotions, and sometimes we can get really stuck. I know I did this when I was younger - I would sit and listen to really sad music for hours - and I would just - and, thankfully, I had the uh - the baseline emotion regulation skills to keep myself safe —

Erica: Mmm —

Marissa: Um, but a lot of our kids - you know, if they do spend 4 to 5 hours listening to sad music, it could lead them to harming themselves - harming others - and just really being stuck in an unsafe place. So that’s how we kinda focus on emotion regulation and distress tolerance, is how does music effect us, and and the emotion regulation piece - how can music help us move to a different place - and then also, how do we use music as distress tolerance - like, do - can we use music as a distraction? Can we use any kind of sound as a distraction? Or, is it soothing - can it help us through these moments to where we can then be safe neough, talk to our therapist, talk to a friend, talk to a family member. An example is we create different playlists. And so, right now, I’m working with a patient individually, and we have created an ups a downs and a neutral playlist for them. And so I kinda preface it with, like, okay, we’re gonna go through your preferred music and what you normally listen to, and I’m gonna challenge you to put each of the songs in one of the 3 playlists.

Erica: Mmm.

Marissa: Does this song move me to a more uplifted state of mind, you know, whether it be does it energize me - does it make me feel happy, excited? Does it bring back a good memory? Um, and then we focus on, you know, does this song bring you down. Or does it validate a more low, unsafe emotion? I try not to use positive or negative, because it’s kind of more of a spectrum - it’s a balance. So yeah, does this song bring you down - you know, will it keep you in the same spot if you listen to it, essentially.

Erica: Mmm.

Marissa: Um, you know, what is the lyric content? Are there things that could possibly be triggering for you - that could even bring you down even more? And then, also, you know, is this song neutral? You know, it’s just a song and I like it, and I don’t have a reaction to it - and that’s okay. And, you know, those can be used for, you know, relaxation - distraction - kind of more neutral distress tolerance type skills.

Erica: Awesome. Um, for patients that are able to see you, as a music therapist on the unit, what is the overall response - and what is the response also from the other professionals on your team that you’re working with?

Marissa: The response from the patients has been great overall. They’re very excited to be engaging in something just different - something different than, you know, sometimes we don’t have to talk about anything - you know, we can have a music experience that is supporting a DBT concept - that they already know and that they’re learning - but they just don’t know we’re working on that.

[Erica chuckles]

Marissa: It’s sneaky, and it’s a - it can be a mental break for them. And I think it’s also - especially for the adolescents, they’re music therapy time gives them the opportunity to kind of unapologetically like be themselves. Like, they get to be silly if they want, they get to be sassy if they want - they get to share their music - they get to learn more about each other. And it’s not so focused on the unsafe behaviors, where, you know, when they’re meeting with their team - meeting with their family - you know, they have to talk about those really hard things verbally. You know, like - like, you know - pretty much like 80% of the time, they’re talking about what happened - why did they come to the hospital - what behaviors they need to stop doing - all of this hard work that they had ahead of them. But, you know, when we’re in music therapy, we don’t necessarily have to explicitly talk about all those things. So I think it kinda gives them a sigh of relief.

The response from all of the other providers, and our leadership team - our management team, has also been super great and supportive. And everyone, you know, definitely - I think because I worked there for a year, and I got to like plant little seeds, and give little nuggets of information, that really helped everything not be so overwhelming. ‘Cause I think that, for like a psychiatrist, for example, their theoretical orientation and schooling experience is very… specific —

Erica: Mmm —

Marissa: So when we bring a whole new kinda left field way of providing treatment, you know, there’s a lot for them to learn - and sometimes it can be a little off-putting. But I think it’s great, because our culture at Seattle Children’s is that we are innovative - meaning like relentlessly curious - like, no matter what situation we’re in, like, we’re always gonna try to think outside the box - a hundred percent of the time. And I really appreciate, you know, everyone kinda stretching their mind a bit, and being willing to do that, because it’s really making a positive impact on the treatment that we’re providing. And so I’m very thankful for that.

Erica: That’s super cool - it’s super cool that it’s so - it’s such a supportive atmosphere, both from the patient response and from your colleagues. Um, for families that are coming to Seattle Children’s, how can they request or look into receiving music therapy services?

Marissa: Yeah, absolutely. So, if they are um being admitted to not the psychiatric unit - um not the PBMU, then they can request um, you know, with their nurse or their provider, saying, hey, like, I think my child would benefit from music therapy - and then our 3 music therapists who are in the Child Life department - across the whole hospital - they will receive that referral —

Erica: Mmm —

Marissa: And then triage out. And uh - triage meaning like they will um figure out who would be the best fit to go meet with that family. For the psychiatric unit, right now, I’m only - because I’m working there 2 days a week, I work with the adolescent group, so ages uh 13-17. So if there are patients being admitted to the PBMU, they will receive music therapy from me. And then we also have our other music therapists who come and provide music therapy for our younger kiddos - and for a couple of our other groups as well.

Erica: Okay, awesome. So basically, just make it known that that’s what you want, and it will find it’s way to somebody that knows what’s happening —

Marissa: Yes! Absolutely —

Erica: And a therapist will come see the family eventually.

Marissa: Yes.

Erica: Yes. Awesome! Um, for students who are maybe looking to be music therapists, or a social work program - other types of like helping professions, and they want to know more abut DBT - or look into more trainings or what not, do you have any resources that can be helpful?

Marissa: Yes. The first place I would go to learn more about DBT is on Psychology Today. Psychology Today has a great overview of DBT, and also a few articles that they have written about the effectiveness of DBT in different populations that you typically would work with. Also, a great place to look at would be uh the University of Washington, um because Marsha Linehan was the one who created DBT, and she currently still works um at the University of Washington. So looking through their resources um through UDub. And for uh music therapy and DBT specifically, I would check out TheSpiegelAcademy.com. So that’s Debora Spiegel - she’s a music therapist who has been developing DBT-informed music therapy online courses, for music therapists to become more proficient at using DBT skills in their work.

Erica: Awesome. Um, Marissa has already sent me some of these links, so I will go ahead and put the links, like usual, in our episode notes - on our website. If you want to learn more about the podcast, or look up a transcript, anything like that, our website is S as in Sam - C as in Cat - Music Project dot org (scmusicproject.org). You can also follow us on all social media @SCMusicProject.

Next week is the first week of June, and we’ll be started a little mini Pride celebration on the podcast. Uh, Vee will be back with us, and talking about uh music therapy with LGBTQ youth, and also the concept called queering, which is something that they have been part of really defining and really building a movement behind that - and then how does that apply across different music therapy disciplines. So I’m really excited for that.

Thank you, Marissa, so much for chatting with me today. Marissa’s awesome - Marissa’s also the president of the Music Therapy Association of Washington, so if you are just interested in music therapy in general in Washington State, you can check out that website, which is MusicTherapyWA.org. Thank you, listeners, for listening. And we’ll talk to you next time.

[Podcast outro music plays]