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#43: Distress Tolerance Overview Part 2

The Distress Tolerance skills in DBT offer creative ways to get through challenging situations without making things worse. 

In Part 2 of this overview of Distress Tolerance skills, we focus on acceptance skills. Both acceptance and change skills can help lower emotional distress so you can access your most wise, grounded self. Radical Acceptance, as well as skills that support Radical Acceptance, are covered in this episode.

Show Highlights

  • Some signs that you are rejecting reality are feeling stuck, resentful, or hopeless
  • The most common obstacle to rejecting reality is conflating acceptance with approval
  • Reality acceptance is the necessary starting point that precedes effective and meaningful change
  • Everything is always changing
  • We can’t change the past but we can change our relationship to what has happened in the past
  • Radical Acceptance is an ongoing process
  • You will a have a relationship to past trauma and losses for the rest of your life
  • Radical Acceptance allows you to say “This is where I am today.”
  • Fighting against threats is built into us
  • Radical Acceptance doesn’t mean we don’t work towards change
  • The absence of emotion is not the barometer of whether this this skill is working 
  • Turning the Mind points us in the direction of Radical Acceptance 
  • Cultivating a willingness to do what’s effective
  • Notice and label when you’re being willful or fighting against reality
  • Willing Hands and Half-Smile help you physically express acceptance and openness

DBT Skills Discussed

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#43: Distress Tolerance Overview Part 2 Transcript

Marielle Berg 

Hello and welcome to The Skillful Podcast where we explore DBT and RO-DBT skills to help you reduce emotional suffering, improve your relationships, and become more present in your life. I’m your host, Marielle Berg, a psychotherapist at the Bay Area DBT and Couples Counseling Center.

Marielle Berg 

We are continuing today talking about Distress Tolerance, focusing more on reality acceptance skills.

Ed Fowler 

When we talked about doing an episode on Distress Tolerance and the big picture of how it all fits together, we thought it would be one episode and it’s turning into two. And because there’s just so much there with Distress Tolerance. And so I do think it’s valuable to spend a little time talking about the acceptance skills within Distress Tolerance, and then a little bit more about okay, and when don’t we use Distress Tolerance? When would we want to look for something besides Distress Tolerance?

Marielle Berg 

And just as a quick review, our last episode focused on the skills, that we’re referring to, the change oriented skills. So these are skills that help you kind of do something different or differently when you are experiencing overwhelming emotions. And we also have a whole set of skills that are much more around accepting reality as it is because that is a huge and important piece of getting through difficult moments in life.

Ed Fowler 

That the thinking behind these more reality acceptance skills as a form of Distress Tolerance is that very often when we’re in a lot of distress, it’s because we are judging reality, instead of accepting it and saying, it shouldn’t be this way. I hate it. I wish it was different. I can’t do anything until this situation changes. And so often in life, we don’t, we don’t have that power. And there are very difficult, challenging, stressful things that happen. And accepting this is happening, oftentimes does reduce our distress versus fighting against reality.

Marielle Berg 

And when we’re fighting against reality, we usually feel worse. We feel stuck, resentful, angry.

Ed Fowler 

Hopeless. Again, it really does get us more into the extremes of emotions.

Marielle Berg 

The most common objection to accepting reality is thinking that that means you are saying that reality is okay, or whatever the circumstances that are present are okay. And therefore you shouldn’t work to make things better, or different, or fight for change. And that that’s not what we’re saying, or that’s not what we’re talking about.

Marielle Berg 

When we refer to reality acceptance. What we’re talking about is reality acceptance as the starting point, as a necessary starting point, that precedes any kind of action or work towards change. Because when we can’t fully accept and kind of look, whatever is happening, or has happened in our lives squarely in the face, so to speak, it’s very hard to take effective action towards change. Towards meaningful change.

Ed Fowler 

And this is where I think we can we can struggle and our distress can get really high is when we bounce back and forth between acceptance and change, instead of trying to find a flow between them. And so oftentimes, I know for me, I’ve experienced this of like, there is something happening that I don’t like, I want it to be different. And I’m going to change it, I’m going to change it, I’m going to try this, I’m going to try that. And then it doesn’t work, and the situation doesn’t change.

Ed Fowler 

And then I can easily get into this really intense distress and say, it will never change. Nothing will help. I am stuck with this forever. I can’t stand this. I can’t tolerate this. This is horrible. And the reality is, everything changes and even things that feel really stuck can change. For me, I’m so much less effective and figuring out how to change when I’m saying I hate this. This is terrible. It has to change. Why Isn’t anything working? Instead of saying this is it. This is the situation. I don’t know what to do. This is where I’m at, which can bring down that fight, enough to be more open to change based options.

Marielle Berg 

Yes. And as you were talking, I could just imagine that kind of stance sort of quickly bringing down one’s overall sense of distress. Like this is what’s happening. This is reality right now, and letting go of that, that struggle that fight against it that wishing that hoping that all of those things that happen when we are faced with painful realities.

Marielle Berg 

And this applies even for things in the past. Because yes, everything is always changing. And we talked about that, in our episode on dialectics, that change is really the only constant. But even with things that have happened in the past, that we can’t do anything about now, our relationship, or the way we think about or relate to whatever has happened in our past, that can and does change.

Ed Fowler 

And that’s where the relief from distress often comes around stuff that’s happened in the past is, the starting point really is like, okay, that happened. And here’s what that was like, for me. And here are my thoughts and feelings about that now. Is there a way to change my thoughts and feelings, my perspective, my approach, so that it doesn’t feel overwhelming or like, like, I can never get over this pain from the past?

Ed Fowler 

And so the core reality, acceptance skill in DBT is Radical Acceptance, accepting all the way completely, wholly, that this is reality, whether it’s about the present or the past. And being able to just say, Okay, that is what it is. And again, like the fight against it, I hate that reality, I can’t change it. It’s, I’ll never get past it. Like people get past stuff all the time. And it’s really hard to get past painful stuff, it takes effort, it takes energy, it can be excruciating, the process of trying to get past painful stuff. And we can get past it, with some effort.

Marielle Berg 

Yes, and for some very painful stuff that is in folks’ paths, you know, things that very often we had no control over. And here we’re referring to any kind of trauma that may have happened, absolutely it can be worked through or get past, as you said, Ed. And I don’t want folks to think that they haven’t radically accepted, if painful stuff about past events comes up again, even if you’ve gone through a process of Radical Acceptance.

Marielle Berg 

Because as you go through your life, your relationship to things that have happened in the past that have been painful will shift too. So you may have really worked through something and it doesn’t sort of dominate your life in the same way at all. And something might happen, a new life stressor, maybe the birth of a child, or a divorce, or a move, or things happen, or a pandemic that might make us vulnerable, again, to having some challenging emotions or thoughts about things that have happened. And then you can turn again to Radical Acceptance. So I think of Radical Acceptance really, as an ongoing process, right.

Ed Fowler 

And again, the the dialectical approach that we can change our relationship to reality, whether it’s things that have happened in the past or in the present, and that doesn’t mean that they are not painful. And the pain can change and the pain come back. Where, again, an aspect of distress that we often fall into is things do change. And sometimes that means like, Oh, I thought I was over that. And now it’s back up again. And I’m feeling all the tension and the stress and the worry or whatever it might be, and being able to say, Okay, this is where I am now, what are my options? What can I do? As opposed to oh, no, see, I knew nothing ever changes. I knew I could never get over that. I’ll never get past it, it came up again. And being able to notice if we’re getting into extremes and readjust ourselves.

Marielle Berg 

Related to that, one thing I like to keep in mind is that for really hard things, and you know, we could have a list of very painful things that happen to us as humans, you know, death of a loved one or serious physical illness or other kinds of losses or trauma and violence, all those kinds of things. Very often we will have a relationship to those things for the rest of our lives, there will be some way we are relating to them.

Marielle Berg 

And with Radical Acceptance, and of course, other skills that we talk about in DBT, and of course, any other kind of healing that that works for you, the hope is that those things can be in the background, kind of not sort of dominating your thoughts or your actions, rather than in the foreground, which is what happens with more undigested trauma. But it doesn’t go away. If you lost a parent, when you were young, you will have a relationship to that loss for the rest of your life.

Ed Fowler 

Again, this does come up with, with grief in particular. Our relationship to grief changes. And some things, some losses are so painful that we will feel that pain. Again, what we’re looking for is to not feel it as intensely every day. Being able to recognize that the relationship to the loss does can change and does change, Radical Acceptance as a skill in DBT gives us the opportunity to just say, this is where it is today. This is what happened, this is what I’m thinking and feeling today. I’m just accepting that this is where I am. So that we don’t put a lot of energy into I hate this, I wish it would go away. Why won’t it go away? Just like this is. And that can open us.

Ed Fowler 

For me, when I think about Radical Acceptance. I’m a very change oriented person in general. And I find Radical Acceptance to be challenging and so valuable. Because if I’m just focused on change, change, change, I will miss things. And being able to say, Okay, let me pause and accept that this is where things are, this is what I feel this is what happened, then I often, that’s the opening for, okay, I could do this, that would move towards change.

Marielle Berg 

So it, it’s it sounds like it really opens things up and get you to slow down, which doesn’t mean that you abandon change. But you approach it, it sounds like it was a different kind of energy or perspective, when you can deeply, radically accept something.

Ed Fowler 

And this is where I find Radical Acceptance as a Distress Tolerance skill to be so helpful is when I notice that I’m like really tense because I’m fighting reality, like I really do need to notice that and slow it down and try to accept, in order to not be wasting energy with all that tension. So that I can have openness, my distress level can be low enough, I can think clearly I can access Wise Mind, I can think about options. And for me, when I’m like oh my god, this has to change. This is horrible. I hate it, I hate it, I hate it. That’s my sign of like, I probably need to focus a bit on acceptance, so that I can be in Wise Mind and approach change from a different perspective.

Marielle Berg 

I like Ed, that you mentioned how much energy it takes to fight reality. Because it really does. And I think it happens in big and small ways. So we referenced a lot of some of the you know, the more traumatic things that happen in life, losses and other kind of overwhelming very painful things. But I’m thinking today just about a small way that I’m sort of fighting reality or in a fight with it, and how that leaves me sort of in a knot. And I’m expending extra energy that I don’t need to.

Marielle Berg 

So where I am today, it happens to be quite humid, which is unusual. And so I’ve been sort of irritable and kind of cranky about it all day. And like why is it like this and I can’t believe it’s so humid, and it’s not supposed to be like this here, you know, in the Bay Area where we usually don’t have a lot of humidity and I’m sort of amping up my distress level over a small thing. And if I could bring the energy of Radical Acceptance. This is what the weather is today. How can I make myself as comfortable as possible, knowing it will likely pass? Instead of being in a tussle with it, in a fight with something that I actually can’t do that much about.

Marielle Berg 

And when I can step back and say okay, this is what’s happening, then I can think a bit more broadly. Alright, maybe I want to make sure I’m wearing some light clothing. Maybe I want a cold drink next to me. Maybe today is not the day to do some intense aerobic activity.

Ed Fowler 

No,

Marielle Berg 

So options can really open up.

Ed Fowler 

definitely not.

Marielle Berg 

Although people who always live in, you know, humid climates to probably get used to it.

Ed Fowler 

For me, like I’m very aware, another aspect of acceptance is that as humans we do this. Something seems threatening and we fight against it. And sometimes it’s because this is legitimately threatening to our personal safety, our security, our sense of self. And the instinct to fight against this threat is built into us. This is part of being human. We also, as humans apply that to the weather that we can’t fight – it doesn’t matter how much I hate the heat. I can’t stop it from being hot.

Ed Fowler 

And so being able to just notice, and this is where the Mindfulness skills are so helpful to just notice what’s happening right now? I’m so tense. My thoughts are racing, what’s going on? Oh, I’m fighting against the heat. I don’t want that I, I wish it was different. Okay, it’s hot, humid today, what can I do? What are my options? That’s a different approach than Oh, I shouldn’t be upset about the weather. Or, of course, I’m upset about the weather, the weather is horrible. But being able to just be in that in between, of things happen, that are very painful, I have a natural instinct to be upset about it. And I have the ability to access my Wise Mind and figure out what do I need to accept? What might I change? How do I move forward?

Marielle Berg 

With this example, I want us to keep in mind that when we’re talking about Radical Acceptance, we are not against change, or it doesn’t mean we we don’t work towards change, if that’s something that’s important to us.

Marielle Berg 

So with this example, around the humidity, or heat or whatever other kind of weather conditions there are, there is kind of the personal, like what you might be able to do to make yourself more comfortable in the moment. And then there’s also the political, if that’s important to you, and you feel passionate about it, maybe you want to take action, to fight climate change. Maybe there’s different things you want to do for the environment.

Marielle Berg 

So we’re not saying that just you know, radically accept that the weather is the way it is, or whatever else is happening to you and in the world, and don’t, you know, get politically active or go to protests or try to create change in the world. But first, the very first step, is fully and completely, radically accepting what is happening. And then you can think about, okay, what do I want to do about this? What can I do?

Ed Fowler 

Okay, I bristle against an approach of like, well, that’s just how it is, you can’t change that, just accept it. Because for me that has a flavor of approving of our reality that we may not like. And Radical Acceptance is about I’m accepting the reality as it is, aware that I can change that at times. Some things we can’t change, and we just accept, some things we can. So that if I don’t like what’s happening in the world, I can, there are ways to get involved in influencing that.

Ed Fowler 

And an approach that says that’s just how the world is there’s nothing to be done about it, for me is not acceptance. That’s missing that like, okay, yeah, that is the world way the world is now, from my perspective, other people may have a very different perspective. And I want to do these things to influence how the world is. And so Radical Acceptance as a skill for Distress Tolerance really is about putting down the fight against reality. And embracing the possibility of both accepting this is what it is, and what are some possibilities of change from a place that’s not in high distress?

Marielle Berg 

Yes, yes. That’s the key point here, that we want to be acting from our Wise Mind as much as possible. And I don’t think we’ve said this directly, but we’re talking around it. Acceptance doesn’t equal approval.

Ed Fowler 

Right.

Marielle Berg 

So for radically accepting something, you know. And to go back to what we were talking about a little bit earlier, in terms of something very painful from the past, we’re not approving of it. We’re not saying it was okay, that that happened. But we’re radically accepting that this did happen. And this is what happened. And, and how can I be with that?

Ed Fowler 

And sometimes Radical Acceptance, as a way to reduce our distress, is about the back and forth of like, this happened. I hate that it happened. I wish it didn’t happen. And it happened. And it had a big impact on me. And I hate that. And I can’t change that happened. And Radical Acceptance, very often, is allowing that we don’t have to like it. And we can actually really be very, very hurt and upset about things that have happened. And also not saying it shouldn’t have happened and I’m ending there, which tends to get us caught in a trap, and then we’re feeling more pressure. And that increases our distress. Well, it shouldn’t have happened. But it did happen. And so now what? But being able to do a more flexible, it shouldn’t’ve happened. That was that was hurtful. And it did happen. And what do I do? And now I’m back in like, Oh, I hate that it happened. It happened, right? And so Radical Acceptance very often is this back and forth.

Marielle Berg 

Yes. And so sometimes people might feel like they have failed at Radical Acceptance, which you you can’t fail at it.

Ed Fowler 

No.

Marielle Berg 

But as we said, it’s a process. It’s not a one and done kind of thing. And just as I was saying that acceptance doesn’t equal approval, it also doesn’t equal forgiveness or compassion. Those are things that are extraneous to Radical Acceptance. Radical Acceptance also isn’t for others, it’s solely for ourselves. So we can find some kind of peace within ourselves around what is or what has happened.

Marielle Berg 

And on that note, when we are using the skill of Radical Acceptance, we want to be cautious around using it for things that might happen in the future.

Ed Fowler 

Right.

Marielle Berg 

Because we can get into some trouble there.

Ed Fowler 

Yeah, I know, I’ve, you know, I’ve heard people talk about, you know, like, I just need to radically accept that I’m never going to have the job I want. And it’s like, well, how do you know that? Right?

Ed Fowler 

And I think that sometimes our, because again, Radical Acceptance is part of Distress Tolerance. When we’re in distress, we’re looking for a way to reduce it. And sometimes it can feel like, if I just accept that I’ll never get the job that I want, then I can get out, move on with my life and get over it, and it’s no big deal. But the problem is, then that’s not that’s not true. Like, maybe you could find the job you want.

Ed Fowler 

Radical Acceptance is more about like, I can’t, I don’t have the job I want now, it will be hard to find that job, I’m not sure what to do about finding the job that I want. Because I just have to accept that that’s never going to happen. I really haven’t heard people talk about that working, in terms of reducing distress. It tends to be maybe temporary, but then it’s back to like, oh, that’s, that’s terrible, that I can’t have the job that I want. And we don’t give up those hopes, like, I want this, you know, really nourishing and nurturing job. And so acceptance is about, okay, what’s the reality right now. And I’m accepting this in a way to reduce my distress, not to just snap and make my distress go away, and not to like dig into the distress.

Marielle Berg 

Yeah. So when we’re accepting reality, we want to focus on things, of course, that have happened in the past, and things that are currently happening, and to use caution around Radical Acceptance for things in the future. There might be things that really can’t happen. You know, if you’re a woman, and you’re 60, and you never had a child, you will likely not be giving birth to one, unless there’s some major changes that happen in science and research. We could say something that one would have to radically accept but many other things. And like the example you just gave Ed, around someone not, you know, I’m just going to radically accept I’ll never find work I like or that I’ll never find love. We don’t know. So we we can’t accept a lot of things in the future, because we can’t we can’t predict.

Ed Fowler 

And again, I think one of the the measures of is Radical Acceptance helping is does our distress come down? Legitimately does it come down?

Marielle Berg 

Yes.

Ed Fowler 

And so being able to say, I really want a different job, and I don’t know how I’m going to get it. And I am afraid I might not. Oftentimes, if you focus on that, then the tension will come down. I just have to accept that I’ll never get the job I want. Oftentimes, even as I say it, the tension starts to raise. And so we check in to see is, am I accepting the aspects of reality that are going to help reduce my distress? Is my distress going down when I try to work on it?

Marielle Berg 

And on that note, sometimes distress doesn’t go down right away. Because with Radical Acceptance, or one of the reasons why I think we avoid it so often, just as people, is that there can be painful emotions that come with it.

Marielle Berg 

So if we radically accept for example, with the job thing you might feel really sad or disheartened or have regret around choices you’ve made in the past, as you’re working on Radical Acceptance. If we’re thinking about Radical Acceptance for a big loss, a reason why we may not want to do the work of radically accepting is that we’re going to feel more grief.

Ed Fowler 

Right.

Marielle Berg 

So very often when we are radically accepting something that has a lot of charge to it, there’s emotion we have to go through, or move through and feel to get to the other side. So don’t think that you’re kind of doing it wrong if you’re feeling strong emotion, as you’re working on Radical Acceptance. Although it may sound paradoxical, because it’s a Distress Tolerance skill.

Ed Fowler 

Right.

Marielle Berg 

But it will get you there eventually.

Ed Fowler 

And again, I think this is where we recognize there’s a difference between feeling strong emotions that are distressing, because there’s conflict, there’s tension, we’re fighting against the emotion, we’re trying not to feel it, and feeling strong emotions that feel like a relief.

Ed Fowler 

So for instance, with grief, accepting I have had this loss and having a really good cry, can feel really relieving, instead of feeling distressing. Most of us don’t like to have a good cry, we’re crying because there’s grief and loss. And there are times when it’s like, yeah, and then I feel like I’ve moved past something by letting all that pent up emotion out. And so you know, we’re looking not for the absence of emotion, but emotion that feels manageable, emotion that feels like it’s moving, as opposed to emotion that feels stuck, and tense and aggravating, and it’s making things harder.

Marielle Berg 

Yeah, it has a different kind of quality to it.

Marielle Berg 

And another thing I like to keep in mind with Radical Acceptance is the question, what would you do, or what would you do differently if you radically accepted something that’s hard in your life? How would your life be different? What kind of thoughts might you have that are different? Or what kind of actions might you take? And I think that can be an interesting question to reflect on. So thinking about what you would do, if you accepted what seems unacceptable?

Marielle Berg 

And maybe now is a good point to talk about some skills that help support Radical Acceptance?

Ed Fowler 

Yeah, we have like a bunch of skills that that can help us with this process to have accepting reality. So the one of them is Turning the Mind towards acceptance, which is, even when we’re struggling to accept, we can at least point ourself in the direction of acceptance. The difference between, I can’t accept that I won’t accept that, and I am struggling to accept it, and I will try, that’s Turning the Mind.

Marielle Berg 

I also think about Turning the Mind as making a commitment, and sometimes over and over again, to accept reality as it is. It doesn’t mean we are actually accepting or radically accepting, but we’re committing to or we’re saying to ourselves, this is important. So we’re orienting ourselves, or we’re, again, shifting our perspective. And that’s why it’s called Turning the Mind towards acceptance and away from rejection. So I think of this as like the, we might call it the appetizer, to the main course of Radical Acceptance.

Ed Fowler 

Right.

Ed Fowler 

And similar to that is the skill of Willingness, which is cultivating a willingness to be open, to try to accept, to do what’s effective. And again, in terms of Distress Tolerance, trying to cultivate willingness to do the things that will bring down distress, do the things that will help with acceptance, is so important and overlooked, that we want to cultivate that willingness of like I’m going to try even if I don’t want to.

Marielle Berg 

And the first step in practicing Willingness, is noticing when you’re being willful. So that’s the first thing is to notice and label when we’re fighting against reality. That’s how I think about willfulness.

Marielle Berg 

And then radically accepting that you are in that space, that you’re feeling willful, that you’re kind of digging in your heels and doing things to potentially increase your distress and that is sometimes where we find ourselves.

Marielle Berg 

And then turning our mind towards acceptance. And sometimes we have to do this over and over.

Marielle Berg 

And we have a couple of other skills that we have talked about previously that we I think it’s worth mentioning here which are Willing Hands and Half Smile which I think of as ways to radically accept with your body.

Ed Fowler 

So again, this is much like when we talk about TIPP as a Distress Tolerance skill, which is using your body chemistry to bring down distress, Half Smiling and Willing Hands are using your body to kind of physically express acceptance and openness.

Ed Fowler 

So it’s like just the tiniest bit of a smile, not a big fake smile, and not frowning. But just a tiny smile, which really does biologically send a signal to our brain into our body that like I’m a bit more open. And then the Willing Hands part is holding your hands in a willing posture. So generally, with your palms facing up, if you’re sitting down, or your palms facing up, if you’re laying down, or your palms facing out, kind of an, if you’re standing, kind of an open posture.

Ed Fowler 

And holding one or both of these is a physical way to send your body the message I’m trying to accept, I’m trying to be open, I don’t have to fight with clenched fists, and gritted jaw. I’m going to just deal with the tiniest smile and hold open willing hands, and kind of just physically feel more open.

Marielle Berg 

And it’s it sounds like a small thing, but it’s amazing how it can shift how you feel. And before we end, let’s talk a little bit about when not to use these skills.

Ed Fowler 

Yeah, I think that the Distress Tolerance skills in DBT are so valuable. Because when we are in high distress when we’re in a crisis, we want to have things to do, whether it’s the act of change oriented skills, like TIPP, or Distracting or Self Soothing, or more the acceptance oriented skills we want something to do. And one of the things we talked about with Distress Tolerance is Distress Tolerance skills will not help us create a life worth living. We need more. It’s not enough to just be good at tolerating distress. Sometimes we want to deal with what’s creating the distress. And so noticing when we’re in distressing situations regularly, what are some other skills that might help us more than simply tolerating that distress?

Marielle Berg 

So we don’t use, especially the more change oriented distress tolerance skills from our previous episode, we don’t use those to solve life problems because they won’t, and even Radical Acceptance. I mean, that is often the starting point. But we, once we’ve radically accepted or once we began that process, we want to think about other skills, some of our Interpersonal Effectiveness skills, Emotion Regulation skills to help actually make some change or make the changes that you want to see in your life actually happen.

Ed Fowler 

So the way I think about Distress Tolerance is we use these skills to help us get back to Wise Mind. When emotions are high, especially distressing emotions are high, we use Distress Tolerance to get back to Wise Mind, that Wise Mind balance, so that we can figure out what are the Emotion Regulation skills, or the Interpersonal Effectiveness skills, or even the Mindfulness skills that I might need in order to not end up in the same distressing situation again, and again and again?

Marielle Berg 

All right. On that note, I think this might be a good place for us to end.

Ed Fowler 

So good luck practicing acceptance skills and change skills, and thinking about okay, the distress is down, I’m back in Wise Mind, now, what other skills might I apply to get out of the distress altogether?

Marielle Berg 

Thanks for listening to today’s episode. To learn more, or if you’re in the Bay Area and want to get started with therapy, you can find us online at bayareadbtcc.com. That’s BayAreaDBTCC.com