This document provides an overview of Dialectical Behavior Therapy (DBT) training. It aims to enable participants to begin practicing DBT with supervision, provide enough information and skills to be effective practitioners, and offer continued support after training. The training will use an adult learning model of acting, reviewing, reflecting, and planning. DBT is a mix of behavior therapy, validation, and Zen practice using a dialectical view of change. The training will cover the components, stages, and assumptions of DBT as well as the core skills modules of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

1. DBT Training 2014
Part 1
Fiona Kennedy
for
Skills Development Service

2. Aims of the week
 To enable participants to begin
practising DBT with supervision as
soon as they get home!
 To give enough information to allow
practitioners to be effective
 To develop enough skills to allow
practitioners to be effective
 To provide sufficient support after
the week to allow further learning
and safe practice

3. How we plan to do this
 Using the Kolb/Lewin model of adult
learning
act
review
reflect
plan

4. What is DBT?
A mix of behaviour therapy
validation and
Zen practice
in context of dialectical
thinking about change

5. How Dialectics views the
world
 Reality is interrelated and whole
(don’t just look at parts look at
whole)
 Reality isn’t static but made up
of internal opposing forces

6. THESIS ANTITHESIS
SYNTHESIS

7. Dialectical view of thinking
 Both-and NOT either-or
 Black and white and extreme
thinking = not dialectical
 Individual is unable to move to
synthesis
 Can be translated as ‘value
opposites and find the middle
way’

8. Emotional dysregulation
Low threshold
High
intensity
Long
recovery

10.  BIO
 Aspects affecting
development
loosely categorised
as
biological: e.g.
genetics, epigenetics,
neural structures,
hormonal influences,
nutrition
 SOCIAL
 Aspects affecting
development
loosely categorised
as social
environment:
parenting,
stimulation,
friendships,
traumatic events,
abuse, neglect
theory

11. Biology (‘bio’)
 Limbic system reactivity?
 Attentional control?
 Genetic links?
 Environment in the womb?
 Trauma modifying neurology?
 epigenetics

12. Social:
Invalidating environments
 Communication of private experiences is met
by erratic, inappropriate and extreme
responses
 Expression of private emotion is
punished/trivialised - Invalidated
 Intolerant of expressed emotion
 ‘Perfect environments/perfect child’ Be happy,
never give in, there’s nothing you can’t do’
 Behaviours attributed to manipulation/not
trying/hostility

13. Biosocial Theory

14. Component Parts of DBT
Skills Training Group
Individual Therapy
Support for generalisation of
skills – telephone coaching
Consultation Meeting

15. Orienting client to
treatment
Building
commitment
(strategies)
Testing motivation
and ability
Individual therapy
Session agenda
Behaviours to
reduce
Collaborative
behavioural
analysis
Acceptance
Change
Skills group
Learn new skills
Behaviours to
increase
Mindfulness
Interpersonal
Emotion
regulation
Distress
tolerance
Coaching
Give input at
time needed
Close to target
behaviour
Use relationship
Contact also
possible to
repair
relationship
Consult group
Support and
supervision for
therapists
Therapist
assumptions
Recursive
values and
techniques
Role play
Review
Target behaviours
Skills acquired
Clients perception
Discharge
Planned ending
Relapse plan
Goodbye letter?
Post discharge
Stage 2 needed?
If relapse?
Gap between
therapies?
DBT in a nutshell

16. Orienting
client to
treatment
Building
commitment
(strategies)
Testing
motivation
and ability
Commitment (pre-therapy) stage

17. Individual
therapy
Session
agenda
Behaviours to
reduce
Collaborative
behavioural
analysis
Acceptance
Change
Skills group
Learn new
skills
Behaviours
to increase
Mindfulness
Interpersonal
Emotion
regulation
Distress
tolerance
Coaching
Give input at
time needed
Close to
target
behaviour
Use
relationship
Contact also
possible to
repair
relationship
Consult
group
Support and
supervision
for therapists
Therapist
assumptions
Recursive
values and
techniques
Role play
Therapy Stage: 4 aspects

18. Review
Target
behaviours
Skills
acquired
Clients
perception
Discharge
Planned
ending
Relapse
plan
Goodbye
letter?
Post
discharge
Stage 2
needed?
If relapse?
Gap
between
therapies?
Ending DBT therapy

19. Twin Tasks of DBT
 INCREASE
skills
 DECREASE
problematic &
unskilful
behaviour

20. Individual therapy
◦ Target behaviours list
◦ Create a context of validation rather
than blaming
◦ Block or extinguish maladaptive
behaviours
◦ Drag out effective behaviours
◦ Make the effective behaviours so
reinforcing that the client stops
using the maladaptive ones!

21. Further work
 (Linehan)
Stage 2: PTSD
Stage 3: achieve self-
validation and self-respect

22. problem-
solving
validation

23. client therapist

24. Validation (acceptance)
1. Find the nugget of wisdom somewhere
in what the client says/does!
2. Observe and believe in client’s ability to
get out of the misery that is her life and
build a life worth living
Play to client’s strengths, not her fragility

25. Problem solving (change)
 Analyse target behaviours (chain analysis)
 Solution analyses
 Orient client to solution
 Get commitment to engage
 Do it!

26. irreverent reciprocal
Interpersonal styles

27. Consultation to the client
 Strong bias towards client being her own
case manager
 Therapist coaches client how to solve
problems herself
 Inappropriate behaviour of professionals
regarded as learning opportunity

28. Consultation to the environment
 Interventions by DBT therapists to
change the environment, solve
problems, co-ordinate professional
treatment are used when
1. It is important
2. Client clearly is not capable of producing
the outcome

29. Treating the therapist
 Supervision
 Case consultation
 Consult group
 Stay in DBT frame
 Treatment of the therapist is integral to
the therapy

30. Telephone consultation
 Inhibition of asking for help
 Asking for help abusively, demandingly
 Phone provides practice in changing these
patterns
 Generalisation of skills
 Repair of relationship

31. DBT assumptions
 Clients are
doing the best
they can
 Clients want to
improve
 Clients need to
do better, try
harder
 Clients may
not have
caused all
their problems
but have to
solve them
anyway

32. DBT assumptions
 Suicidal clients’
lives are
unbearable as
currently lived
 Clients must
learn new
behaviours in all
relevant
contexts
 Clients cannot
fail in therapy

33. DBT therapist assumptions
 Therapists treating
clients with BPD
need support
 Therapists should
show:
 Warm empathy
 Persistent focus
 Endless hope
 Dialectical view
 Non-
judgmental
stance
 Practice DBT on
themselves and
each other

34. Skills Training in DBT
To learn and refine skills in changing
behavioural, emotional and thinking
patterns associated with problems in
living that are causing misery and
distress.

35. Core Mindfulness
WHAT
Observe
Describe
Participate
 HOW
 Non-judgmental
stance
 Focus on one
thing in-the-
moment
 Being effective:
do what works

36. DISTRESS TOLERANCE
Distracting
Self-soothing
Improving the moment
Radical acceptance
(turning the mind,
willingness)

37. EMOTION REGULATION
Identify and label affect
Obstacles to change
Reducing vulnerability to
emotional mind
Mindfulness to emotion
Opposite action

38. INTERPERSONAL EFFECTIVENESS
Asking and saying no
Coping with conflict
Obtaining desired changes
while keeping the
relationship and one’s own
self-respect

39. Increasing behavioural skills-
SELF-MANAGEMENT
 NOT A MODULE
 Knowing principles of behaviour change
 Realistic goal-setting
 Behavioural analysis skills
 Contingency management skills
 Environmental control
 Relapse prevention
 Tolerating limited progress

40. Consult Groups
 Read and sign therapist
consultation agreements
 Set any other rules you feel
necessary for working as a team
 Discuss how you will manage
lateness/non-attendance
 Read and discuss case study-
how would you usually approach
this case?