Question 1

Can you comment on striking an effective balance between acceptance and change when working with clients?

Marsha Linehan · Accepted Answer

You are asking about the very heart of DBT!  An “effective balance” is one that moves the client toward treatment goals in the most efficient and long-standing way.  Since everything we do in DBT can be categorized as being on the “acceptance” side, or on the “change” side, the therapist has to balance all of the processes, strategies, and skills, while moving the client forward.  Validation, Mindfulness Skills, and Distress Tolerance Skills (acceptance) and strategies for change (cognitive modification, exposure, contingency management, and Interpersonal and Emotion Regulation Skills) are offered as needed, and in a context of skillful non-verbal and verbal behavior of the therapist.  This is where “movement, speed, and flow” come into play-the ability of the therapist to let go of attachment to a single approach, and move in an ever changing dance with the client.

An experienced DBT provider is like a highly skilled archer (think bows and arrows).  They have honed the skill of every movement involved in shooting an arrow to the point of instinct.  When then see a target, they don’t have to think about reaching for an arrow, loading it on the bow, pulling the tension just right, aiming, or shooting with the strength needed.  It is so well practiced that it…just happens.  All the while, the marks-person is focused on the target, becoming the target, anticipating every nuanced movement, so they can make instinctive adjustments.  Knowing all of the strategies and skills for both change and acceptance well allows the therapist to reach for these strategies easily while maintaining focus on the response of the client and to make sweeping or micro adjustments in these strategies as needed.

No one is born an Olympic-level archer.  Becoming the most effective DBT therapist involves dedication to learning and the development of precision in a broad array of strategies.  Some of this learning occurs prior to seeing clients and some of it happens as we stumble through the dance with them.  There are some simple concepts you can hold in mind as you are learning to “participate” as a DBT therapist.

First, most clients will require more validation at the beginning of treatment, and generally less as time goes on.  Once a foundation of compassion is established in the relationship, the therapist becomes a trusted source for change.  Any time painful change must occur (e.g. doing some exposure in the form of mindfulness of emotion, interpersonal effectiveness skills, or observing limits by the therapist) the therapist will do well to wrap that change in more validation.  The skills themselves are often used in an “out of balance” way by clients when they come into therapy.  Most of our clients lean heavily on use of Distress Tolerance Skills, having learned to avoid pain in their lives.  Teaching them to use these skills more carefully, and in good mix with change skills is simply a part of the treatment.

Question 2

What does the research show about the use of DBT skills training as a stand-alone intervention separate from standard DBT?

Marsha Linehan · Accepted Answer

The research examining DBT Skills training as a stand-alone treatment has exploded in recent years, and the data suggests that skills training alone can be very effective in many situations.  However, there are some limits as to what we can conclude about using DBT skills-only as a treatment right now given some limitations of the research.  For instance, studies do not always identify the skills that have been used or left out of their intervention, and measures include widely varying constructs in report of outcomes.  Some “skills-only” interventions include supportive services such as suicide management protocols delivered by highly trained case managers, specific medications, or other elements, while others do not.  Thus, our ability to clearly identify which patients will benefit from a skills-only intervention and under what circumstances is still in the early days.

However, the research to date is promising.  A sampling of the studies examining DBT skills-only treatment reveals benefits to a diversity of populations studied including individuals with and without borderline personality disorder or suicide and self-harm behaviors, men and women with eating disorders, and men and women with major depressive disorder, bi-polar disorder, and ADHD, and problem drinking. Skills-only interventions have been applied to male and female adolescents diagnosed with oppositional-defiant disorder and to family members of people who are diagnosed with BPD or who have attempted suicide.  Comparisons of skills-only to comprehensive DBT and wait list groups have also been conducted.  And this just begins to scratch the surface of the research that has been done!

In brief, results of these studies show that DBT Skill Training as a stand-alone treatment reduces mood dysregulation measured in many ways and across numerous RCT and non-RCT studies (e.g., anger, depression, hopelessness, and PTSD symptoms).  Behavioral changes have been demonstrated in clients receiving DBT Skills-Only including reduced aggression, hospitalizations and binging.   Increases in adaptive coping, emotional processing, and productive behaviors have also been seen. 
   
For a nice summary of the research up to 2014, you can reference The DBT Skills Training Manual (pp. 19-21, Linehan, 2014).  The following article can bring you further up to date on this treatment application:

https://www.psychiatrictimes.com/special-reports/dialectical-behavior-therapy-skills-training-effective-intervention/page/0/1

Question 3

In general, which skills module would you prioritise? Which of the acceptance-oriented and/or change-oriented skills get the fastest and longest lasting results?

Marsha Linehan · Accepted Answer

To date we don’t have data to suggest that one skill module is more important, more effective, or longer lasting than another.  Each has its own role in helping people create and maintain a life they experience as worth living.  The “core” mindfulness skills are called this because we believe they form the base from which all other skills work.  In fact, all of the skills can be thought of as a form of mindfulness—of emotion, relationships, stress, and of the fullest picture of reality.

There are many reasons to prioritize a particular skill, however, all driven by a client’s needs in a specific moment.  At the beginning of treatment, we might offer clients the crisis survival skills to help them manage painful moments when they have few other skills on which to rely.  These skills are fairly self-explanatory and easy to use, giving the client both a lifeline and an early sense of success.  Interpersonal effectiveness skills are helpful when the client is struggling to sort out their goals in an interaction, and then needs help interacting in such a way as to meet those goals.  Mindfulness and the reality acceptance skills can help orient a client who is struggling to focus their attention.  In fact, this is part of the reason we begin each consultation team and skills group with a mindfulness exercise-we all benefit from focusing our minds!

Question 4

What is your opinion on doing skills training during individual sessions? Or should it really be done in a group context?

Marsha Linehan · Accepted Answer

While it is optimal for many reasons to teach skills in a group setting (efficiency, sharing of applications of skills by other group members, etc), there is no requirement for the skills to be taught in a group.  Skills can be conducted in an individual setting for a variety of reasons, though this is considered a rare exception in the treatment.  When it must be done, it is recommended that there be specific time identified for “DBT Individual Therapy” and the skills training portions of treatment.  For instance, some therapists hold two separate sessions per week, one of which is individual, and one of which is skills focused.  If a single, longer session is divided between these two components, then it is suggested that the these two components be separated by a break, and perhaps occur in different rooms, if possible.  This prevents a “processing” type of tendency for the therapist and client.

Question 5

How do I deal with 'excessive venting' when trying to teach DBT skills?

Marsha Linehan · Accepted Answer

This is where you will find a strong pre-orientation to the treatment to be your best ally in everything you do later.  Be clear from the beginning that DBT Skills group is a class-type process focused on teaching each member to learn and practice skills.  Inoculate them against disappointment that it will not be a process or support group—often the only groups that these clients have experienced.  Once this is accomplished in the orientation phase of group, model the way in which people are encouraged to review diary cards (if you include that in your group), review homework, or share important events in their lives.  It is vital to have a direct conversation about how much time each member will have to share (some groups use a timer).

On occasion, even with good preparation, a group member will either “vent” in a highly emotional way or will tend to dominate conversation in group.  Non-judgmental intervention in the moment by group leaders is one approach that can be taken.  This assures other group members that you are aware of the issue and value their input, too.  Sometimes it can be more effective to pull a member who is over-talking aside before/after group or during break to address the behavior.  I have asked clients to be more aware of the balance of sharing in the group.

Question 6

Does a DBT skills-based training group function like a support group?

Marsha Linehan · Accepted Answer

Not in a formal way, but clients often find group to be highly supportive.  It is validating to be in a setting with people who have experienced many of the peculiar things that you have gone through!  We delineate time mid-group for socializing with group members and leaders in order to facilitate practice and use of effective social interactions.  We do not discourage people from socializing outside of group, as our populations are often quite isolated and lonely.  We do discourage forming “private” relationships—dating, best/exclusive friendships—as this makes it difficult for others in the group (remember the cliques in middle school?) and can impede honesty in group or individual therapy when clients rely on each other to keep secrets.

Question 7

Can I do DBT skills training with clients whilst they are actively using substances and/or alcohol?

Marsha Linehan · Accepted Answer

DBT has demonstrated great effectiveness with clients for whom substance abuse is a significant focus of treatment.  Many clients come into DBT while actively using alcohol and drugs and it is not uncommon for our clients to have failed substance abuse treatment one or more times before admission into DBT.

This does not preclude their involvement in the treatment so long as they are able to attend treatment sessions while not appearing to be under the influence of a substance, periods of sobriety are long enough to practice and record skills use and complete homework, and use of substances does not otherwise impede participation in treatment.  We can start with an approximation of the diary card and homework completion and work to shape full completion, just as we do with other clients.  DBT demonstrates good outcomes for these clients relative to substance abuse.

For many clients, use of substances is not an issue they are interested in addressing.  When this is the case, and when we can agree that their use does not lead to life-threatening behaviors or substantially block their ability to achieve life worth living goals, we don’t address it.  When we find that use or abuse of substances is closely linked to life-threatening behaviors or blocks gaining a life worth living, then we fold it into treatment, just as we do with other impulsive/compulsive behaviors in the chain of a problem behavior.

Question 8

Is DBT skills training effective at reducing anger?

Marsha Linehan · Accepted Answer

Absolutely!  Comprehensive DBT and skills-only applications have proven helpful in significantly reducing anger in participants.  This has been a highly consistent finding across studies and populations. In the early RCTs, DBT yielded higher improvements in anger outbursts than either “treatment as usual” (TAU) or treatment by experts, in studies focused on individuals with borderline personality disorder.  In addition, there are at least four studies in which DBT Skills as a stand-alone treatment reduced anger. A good review and discussion of these studies and outcomes is presented in the Skills Training Manual in Chapter 1.

Question 9

I'm interested in DBT skills for ADHD. I get how mindfulness will help with inattention but what helps with the hyperactivity?

Marsha Linehan · Accepted Answer

This is an interesting question, for a couple of reasons.  First, it highlights the importance of applying multiple skills when trying to address behaviors.  In one sense, all of the skills modules address attentional issues because they all increase awareness/mindfulness in different aspects of our lives: mindfulness of internal experiences, relationships, emotions, and distress.  These are all areas of life on which it is important to sustain attention, and can also present “distractions” that divert focus from reaching our goals.  Our ability to “observe” and “describe” early signs of distraction in these areas can help us keep from veering off-course from our goals and allow more effective “participation” in the important things in life.  For instance, if I know that certain situations are distressing to me and that my attention is likely to be “hijacked”, I might learn to become highly attuned to those early cues so I can head off distraction.

The second thing this question raises is really about how to address the urges that accompany distraction.  A higher than typical level of desired movement (“hyperactivity”) might be seen as  frequent and strong “urges” that can be addressed using several of the skills.  In fact, this is very similar to what happens for an emotionally dysregulated person when an emotion rises up powerfully and an urge to act inevitably follows (e.g., if anger rises up, raise the voice, strike out, etc).

The “observe” skill begins with noticing the tension of that urge in the body.  Then we “describe” the urge: “I just noticed the urge to get up out of my seat and to do something else” (or to look at my phone, etc).  At this point, you have already “treated” the urge, because you haven’t responded to it automatically by getting up out of your seat.  Next, you can continue to “observe” the feeling of tension and the desire to move, without acting.  Noticing the rise and fall of the intensity of the urge, without intervening.  At some point, when you pay attention to urges, they decrease.  This might be the “observing thoughts” or “observing emotion” skill.

Another option is to use Reality Acceptance skills to become “willing” with the urges rather than fighting them.  Deliberately relaxing the body while noticing the urge to tense and move is one way of becoming willing.  Half smile while sitting still with an urge to move is another option.  As soon as practical, you might “turn the mind” back to the task at hand.  There are many examples of skills that can be brought to help with “hyperactivity”, all aimed at increasing awareness and decreasing automaticity of acting on those urges.  Over time, practice of these skills will result in decreased movement through the formation of new habits in responding.

You might be interested in this study looking at the effectiveness of DBT for college students diagnosed with ADHD  
https://journals.sagepub.com/doi/abs/10.1177/1087054714535951

Question 10

Aren't some problems NOT the result of skill deficits?

Marsha Linehan · Accepted Answer

This is very clearly the case with symptoms such as those arising from schizophrenia and bi-polar disorder, where the first line of treatment is medication.  That is not to say that many individuals with these diagnoses do not lack skills, or that skills would not provide a helpful adjunct to medication or other treatment.

For many clients with significant mood and behavioral dysregulation, and certainly for those meeting criteria for borderline personality disorder, the underlying theory is that their symptoms originate from the relationship between a highly sensitive biological emotional system and an environment that is not responsive to the needs presented by that system/person.

The individual experiences strong emotions more frequently, intensely, and for longer periods than do others and if the caregivers/others are not accurate in their response to that reactivity (try to shut it down, ignore it, etc), an escalating pattern of emotionally intense behaviors is established.  For these individuals, skills help them learn to understand and respond with sensitivity to their own powerful emotions, to tolerate painful moments without escalating, to solve problems effectively, and to navigate a social world that is not ideally suited to their needs.

Question 11

Should every individual in a DBT skills group have a similar presentation i.e., same diagnosis?

Marsha Linehan · Accepted Answer

We don’t have any data to suggest either homogeneous or heterogeneous groups have any benefit over the other.  For convenience sake it is sometimes easier to divide clients into separate groups by clinical focus (e.g. cognitive level, substance use, eating disorders, etc).  Given that this is a class, rather than a process oriented group, it is possible to have highly heterogeneous groups and to be successful with diverse issues.

Question 12

What is your opinion on 'DBT-Informed' treatment i.e., giving DBT skills handouts to supplement a different intervention approach?

Marsha Linehan · Accepted Answer

It is important to provide thorough “informed consent” when providing any treatment.  For the type of approach you are suggesting it is vital to make it clear that use of skills handouts does not mean that the consumers are “getting DBT”.  In fact, one would have to say that we simply don’t have any outcome data when the skills are implemented in this manner.  Anyone making use of materials in a novel manner is advised to collect data on the outcomes produced.

Question 13

Is DBT skills training okay for clients who don't want to talk about past and childhood experiences?

Marsha Linehan · Accepted Answer

As a behavior therapy, DBT is largely present-focused.  While we know that behavior patterns often have their origins in the biology and the learning history of a person, resolving problem behaviors is seen as requiring changes to behavior in the current time.  Skills are a big part of how clients learn to change their behavior in DBT.

Skills are taught and practiced in a classroom-like setting that emphasizes teaching, discussion, and exercises.  There is little or no “processing”, as would be done in more traditional psychotherapy groups where the past is considered a more important key to change.  In DBT skills training, clients learn and practice new skills together and share current experiences in using skills via homework review.  Clients often talk about aspects of their own histories in group, but in brief reference.

It is in DBT individual treatment where it may become more important for the therapist to have information about the origins of the client’s current problem behaviors.  For instance, a client who refuses to try new activities due to a fear of failure may benefit from understanding how criticism received as a child may have contributed to the development of this pattern.  When this information allows for a realistic “checking the facts”, they may realize that avoidance is no longer helpful to them.   Thus, treatment planning can be targeted to make behavior change both more efficient and effective.  However, this focus on the past generally does not consume much time in DBT.  Once the historical and current “chain” of events surrounding a behavior are understood, a variety of strategies in addition to skills training may be implemented in order to change current behavior, such as cognitive modification, exposure, and contingency management.

Question 14

Have DBT skills been used with indigenous populations?

Marsha Linehan · Accepted Answer

Given the high rates of suicide and substance abuse among many groups of indigenous peoples worldwide it is no surprise that DBT has been implemented in many of these communities.  DBT is highly effective with these issues in large random controlled trials.  However, to date, no studies have been conducted that address the question as to the particular effectiveness of this treatment for any indigenous group.   Anecdotal and small study outcomes suggest that the treatment is effective across cultures.

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