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Mindfulness and Acceptance in DBT Skills Training. Catherine R. Barber, Ph.D. Baylor College of Medicine DBT Associates of Greater Houston. Objectives. Participants should be able to: Describe and give examples of the primary skills in DBT skills training.

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mindfulness and acceptance in dbt skills training

Mindfulness and Acceptance in DBT Skills Training

Catherine R. Barber, Ph.D.

Baylor College of Medicine

DBT Associates of Greater Houston


Participants should be able to:

  • Describe and give examples of the primary skills in DBT skills training.
  • Describe the concepts of mindfulness and acceptance as they relate to DBT.
  • Identify strategies for balancing problem solving and validation.
  • Conduct a mindfulness exercise.
  • A “taste” of Mindfulness
  • The DBT framework in 15 minutes or less
  • DBT Skills Training overview
  • Mindfulness: theory and practice
  • Acceptance: theory and practice
  • Balancing validation and change
  • How to conduct a mindfulness exercise
the dbt framework
The DBT Framework

Biosocial Theory of Borderline Personality Disorder (Linehan, 1993):

  • Emotional (temperamental) vulnerability
  • Invalidating environment
  • Note that these factors have a transactional relationship.
  • BPD symptoms either function to regulate emotions or are a consequence of emotion dysregulation.
the dbt framework1
The DBT Framework

Theoretical foundations:

  • Cognitive-behavioral therapy
  • Dialectical theory
  • Zen philosophy
the dbt framework2
The DBT Framework

Functions of DBT:

  • Enhance patient capabilities
  • Improve patient motivation
  • Generalize learning to all relevant contexts
  • Structure the environment
  • Enhance therapist capabilities and motivation
the dbt framework3
The DBT Framework

Stages of Treatment (and associated goals):

  • Level 1: Behavioral control
  • Level 2: Non-anguished emotional experiencing
  • Level 3: Ordinary happiness and unhappiness
  • Level 4: Capacity for joy and freedom
the dbt framework4
The DBT Framework

Stage 1 Target Hierarchy:

  • Decrease life-threatening behaviors
  • Decrease therapy-interfering behaviors
  • Decrease quality of life-interfering behaviors
  • Increase behavioral skills
dbt skills training overview
DBT Skills Training Overview

Skills Training Target Hierarchy:

  • Reduce therapy-destroying behaviors
  • Increase skill acquisition and strengthen skills
  • Reduce therapy-interfering behaviors
core mindfulness skills
Core Mindfulness Skills

States of Mind

  • Emotion mind
  • Reasonable mind
  • Wise mind
core mindfulness skills1
Core Mindfulness Skills

“What” Skills

  • Observe
  • Describe
  • Participate

“How” Skills

  • Non-judgmentally
  • One-mindfully
  • Effectively
interpersonal effectiveness
Interpersonal Effectiveness

Involves the balancing act of obtaining/ maintaining:

  • One’s personal objectives (i.e., “wants”)
  • A healthy relationship
  • One’s self-respect
interpersonal effectiveness1





Appear confident





Easy manner


Apologies (no undue)

Stick to values


Interpersonal Effectiveness
emotion regulation
Emotion Regulation

Involves managing emotions through:

  • Identifying and labeling emotions
  • Decreasing vulnerability to negative emotions
  • Increasing positive emotions through behavioral activation
  • Decreasing suffering through mindfulness of emotions
  • Changing emotions through opposite action
distress tolerance
Distress Tolerance

Crisis Survival Skills

  • Distraction
  • Self-soothing
  • Improving the moment
  • Pros and cons
distress tolerance1
Distress Tolerance

Guidelines for Accepting Reality

  • Observing the breath
  • Half-smile
  • Awareness exercises
  • Radical acceptance
  • Turning the mind
  • Willingness
a definition of mindfulness
A Definition of Mindfulness

Focusing attention

on one thing at a time,

in the moment,


  • Is the opposite of being on automatic pilot.
  • Is the opposite of multi-tasking.
  • Is not pushing away from/suppressing an experience.
  • Is not clinging to an experience.
  • Is related to, but not synonymous with, mentalizing.
mindfulness in practice
Mindfulness in Practice
  • Mindful breathing
  • Mindful eating
  • Mindful walking
  • Mindfulness of the positions of the body
  • Mindfulness of emotions
  • Free association, behavioral diaries, thought records, reflective responding
  • Metaphors for mindfulness
a definition of acceptance
A Definition of Acceptance

Acknowledging reality

just as it is,

without censoring or denying,

while being open to possibilities.

  • Is the opposite of refusal to tolerate an experience.
  • Involves willingness, which is the opposite of willfulness.
  • Does not require liking or condoning.
  • Is radical: Everything is as only it can be.
  • Validates experience.
acceptance in practice
Acceptance in Practice
  • Being a “gracious host”
  • Turning the mind
  • Awareness exercises
  • Effective decision-making
  • Metaphors for acceptance
validation in dbt
Validation in DBT

What is validation?

  • Staying awake
  • Accurate reflection
  • Articulating the unspoken
  • Validating in terms of past experiences
  • Validating in terms of current experiences
  • Radical genuineness

Linehan, 1997

why validate
Why Validate?
  • Reinforces progress
  • Strengthens therapeutic relationship
  • Promotes self-validation
  • Provides feedback
  • Balances change strategies
balancing acceptance and change
Balancing Acceptance and Change
  • Remember that neither acceptance nor change is sufficient; both must be present.
  • Each person requires a different acceptance : change ratio.
  • Favor validation strategies:
  • Early in treatment
  • During extinction
  • When change is especially difficult
balancing acceptance and change1
Balancing Acceptance and Change
  • Favor change strategies:
  • Later in treatment
  • When the behavior is high-risk
  • When commitment is high
  • Combine validation and problem-solving:
  • Throughout treatment
  • During behavioral chain analysis
  • During homework review
is dbt effective
Is DBT Effective?

DBT Research to date:

  • 9 randomized controlled trials
  • 6 independent sites
  • Principal Investigators: Bohus, Koons, Linehan, Lynch, Safer, Telch, Verheul
  • Additional RCTs in progress

Lynch et al., 2007

outcomes across studies
Compared to TAU, Standard

Comprehensive DBT reduces:

Suicidal behaviors

Intentional self-harm




Eating problems

Substance dependence



Emergency Room visits

Compared to TAU, Standard

Comprehensive DBT increases:

Overall adjustment

Social adjustment


Treatment adherence

Lieb et al.,2004

Outcomes Across Studies
additional outcome data
Additional Outcome Data
  • Maintenance of improvements have been demonstrated up to 2 years post-treatment.
  • DBT was also superior to treatment by experts in a randomized controlled trial (Linehan et al., 2006).
  • DBT was equal to APA Guidelines-based general psychiatric management by experts (McMain et al., 2009).
  • DBT has demonstrated promising results with other populations, including individuals with depression (e.g., Lynch et al., 2003, 2006) and eating disorders (e.g., Safer et al., 2001).
additional outcome data1
Additional Outcome Data
  • Some evidence (Linehan, Heard, & Armstrong, 1993) suggests that adding skills training to TAU does not improve outcomes.
  • Preliminary results from an ongoing dismantling study (Linehan, unpublished) suggest that skills training plus skills coaching may be sufficient for less severely disturbed patients.
how to conduct a mindfulness exercise
How to Conduct a Mindfulness Exercise
  • Tell a personal story related to the exercise.
  • Make it simple (not necessarily easy).
  • Anticipate and give instructions about “wandering” mind.
  • Use a mindfulness bell.
  • Lead the exercise.
  • Ask for feedback.
  • Use coaching.

Linehan, 2010

dbt associates of greater houston 832 384 1575
DBT Associates of Greater Houston 832-384-1575
  • Catherine Barber, Ph.D.
  • Laura Devitt, J.D., LMSW
  • Valerie George, LMSW
  • Pat Hartmann, RN, CNS
  • Jennifer Markey, Ph.D.
  • Marki McMillan, LCSW
  • David Moore, LCSW
  • Brett Needham, LCSW
  • Jennifer Urbach, LCSW