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. • Describe the concepts of mindfulness and acceptance as they relate to DBT. • Identify strategies for balancing problem solving and validation. • Conduct a mindfulness exercise.
Agenda • 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 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 Framework Theoretical foundations: • Cognitive-behavioral therapy • Dialectical theory • Zen philosophy
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 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 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 Skills Training Target Hierarchy: • Reduce therapy-destroying behaviors • Increase skill acquisition and strengthen skills • Reduce therapy-interfering behaviors
Core Mindfulness Skills States of Mind • Emotion mind • Reasonable mind • Wise mind
Core Mindfulness Skills “What” Skills • Observe • Describe • Participate “How” Skills • Non-judgmentally • One-mindfully • Effectively
Interpersonal Effectiveness Involves the balancing act of obtaining/ maintaining: • One’s personal objectives (i.e., “wants”) • A healthy relationship • One’s self-respect
Describe Express Assert Reinforce Mindfully Appear confident Negotiate Gentle Interested Validate Easy manner Fair Apologies (no undue) Stick to values Truthful Interpersonal Effectiveness
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 Crisis Survival Skills • Distraction • Self-soothing • Improving the moment • Pros and cons
Distress Tolerance Guidelines for Accepting Reality • Observing the breath • Half-smile • Awareness exercises • Radical acceptance • Turning the mind • Willingness
A Definition of Mindfulness Focusing attention on one thing at a time, in the moment, non-judgmentally.
Mindfulness… • 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 • 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 Acknowledging reality just as it is, without censoring or denying, while being open to possibilities.
Acceptance… • 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 • Being a “gracious host” • Turning the mind • Awareness exercises • Effective decision-making • Metaphors for acceptance
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? • Reinforces progress • Strengthens therapeutic relationship • Promotes self-validation • Provides feedback • Balances change strategies
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 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? 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
Compared to TAU, Standard Comprehensive DBT reduces: Suicidal behaviors Intentional self-harm Depression Hopelessness Anger Eating problems Substance dependence Impulsiveness Hospitalizations Emergency Room visits Compared to TAU, Standard Comprehensive DBT increases: Overall adjustment Social adjustment Self-esteem Treatment adherence Lieb et al.,2004 Outcomes Across Studies
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 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 • 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 • 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