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Mindfulness and Acceptance Mindfulness and Acceptance in DBT Skills Trainingin DBT Skills Training
Catherine R. Barber, Ph.D.Catherine R. Barber, Ph.D.Baylor College of MedicineBaylor College of Medicine
DBT Associates of Greater HoustonDBT Associates of Greater Houston
ObjectivesObjectives
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.
AgendaAgenda
• 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 FrameworkThe 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 FrameworkThe DBT Framework
Theoretical foundations:
• Cognitive-behavioral therapy
• Dialectical theory
• Zen philosophy
The DBT FrameworkThe 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 FrameworkThe 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 FrameworkThe 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 OverviewDBT Skills Training Overview
Skills Training Target Hierarchy:• Reduce therapy-destroying behaviors• Increase skill acquisition and strengthen skills• Reduce therapy-interfering behaviors
DBT Skills Training OverviewDBT Skills Training Overview
PROBLEMS in BPD SKILLS in DBT
Identity confusion Core mindfulness skills
Impulsivity Distress tolerance
Emotional instability Emotion regulation
Relationship problems Interpersonal effectiveness
Self-punishment Self-management
Core Mindfulness SkillsCore Mindfulness Skills
States of Mind• Emotion mind
• Reasonable mind
• Wise mind
Core Mindfulness SkillsCore Mindfulness Skills
“What” Skills• Observe• Describe• Participate
“How” Skills• Non-judgmentally• One-mindfully• Effectively
Interpersonal EffectivenessInterpersonal Effectiveness
Involves the balancing act of obtaining/ maintaining:• One’s personal objectives (i.e., “wants”)• A healthy relationship• One’s self-respect
Interpersonal EffectivenessInterpersonal Effectiveness
• Describe
• Express
• Assert
• Reinforce
• Mindfully
• Appear confident
• Negotiate
• Gentle
• Interested
• Validate
• Easy manner
• Fair
• Apologies (no undue)
• Stick to values
• Truthful
Emotion RegulationEmotion 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 ToleranceDistress Tolerance
Crisis Survival Skills• Distraction
• Self-soothing
• Improving the moment
• Pros and cons
Distress ToleranceDistress Tolerance
Guidelines for Accepting Reality• Observing the breath
• Half-smile
• Awareness exercises
• Radical acceptance
• Turning the mind
• Willingness
A Definition of MindfulnessA Definition of Mindfulness
Focusing attention
on one thing at a time,
in the moment,
non-judgmentally.
Mindfulness…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 PracticeMindfulness 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 AcceptanceA Definition of Acceptance
Acknowledging reality
just as it is,
without censoring or denying,
while being open to possibilities.
Acceptance…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 PracticeAcceptance in Practice
• Being a “gracious host”
• Turning the mind
• Awareness exercises
• Effective decision-making
• Metaphors for acceptance
Validation in DBTValidation 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 ChangeBalancing 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 ChangeBalancing 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 StudiesOutcomes Across Studies
Compared to TAU, StandardComprehensive DBT reduces:• Suicidal behaviors• Intentional self-harm• Depression• Hopelessness• Anger• Eating problems• Substance dependence• Impulsiveness• Hospitalizations• Emergency Room visits
Compared to TAU, StandardComprehensive DBT increases:• Overall adjustment• Social adjustment• Self-esteem• Treatment adherence
Lieb et al.,2004
Additional Outcome DataAdditional 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 DataAdditional 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 How to Conduct a Mindfulness ExerciseMindfulness 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 DBT Associates of Greater HoustonGreater Houston
832-384-1575 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