Mindfulness and Acceptance in DBT Skills Training

1. Mindfulness and Acceptance in DBT Skills Training Catherine R. Barber, Ph.D. Baylor College of Medicine DBT Associates of Greater Houston

2. 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.

3. 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

4. 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.

5. The DBT Framework Theoretical foundations: • Cognitive-behavioral therapy • Dialectical theory • Zen philosophy

6. 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

7. 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

8. The DBT Framework Stage 1 Target Hierarchy: • Decrease life-threatening behaviors • Decrease therapy-interfering behaviors • Decrease quality of life-interfering behaviors • Increase behavioral skills

9. DBT Skills Training Overview Skills Training Target Hierarchy: • Reduce therapy-destroying behaviors • Increase skill acquisition and strengthen skills • Reduce therapy-interfering behaviors

10. DBT Skills Training Overview

11. Core Mindfulness Skills States of Mind • Emotion mind • Reasonable mind • Wise mind

12. Core Mindfulness Skills “What” Skills • Observe • Describe • Participate “How” Skills • Non-judgmentally • One-mindfully • Effectively

13. Interpersonal Effectiveness Involves the balancing act of obtaining/ maintaining: • One’s personal objectives (i.e., “wants”) • A healthy relationship • One’s self-respect

14. Describe Express Assert Reinforce Mindfully Appear confident Negotiate Gentle Interested Validate Easy manner Fair Apologies (no undue) Stick to values Truthful Interpersonal Effectiveness

15. 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

16. Distress Tolerance Crisis Survival Skills • Distraction • Self-soothing • Improving the moment • Pros and cons

17. Distress Tolerance Guidelines for Accepting Reality • Observing the breath • Half-smile • Awareness exercises • Radical acceptance • Turning the mind • Willingness

18. A Definition of Mindfulness Focusing attention on one thing at a time, in the moment, non-judgmentally.

19. 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.

20. 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

21. A Definition of Acceptance Acknowledging reality just as it is, without censoring or denying, while being open to possibilities.

22. 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.

23. Acceptance in Practice • Being a “gracious host” • Turning the mind • Awareness exercises • Effective decision-making • Metaphors for acceptance

24. 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

25. Why Validate? • Reinforces progress • Strengthens therapeutic relationship • Promotes self-validation • Provides feedback • Balances change strategies

26. 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

27. 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

28. 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

29. 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

30. 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).

31. 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.

32. 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

33. 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