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