Mindfulness and Acceptance in DBT Skills Training Catherine R. Barber, Ph.D.

Mindfulness and Acceptance
in DBT Skills Training
Catherine R. Barber, Ph.D.
Baylor College of Medicine
DBT Associates of Greater Houston
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.
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
• BPD symptoms either function to regulate
emotions or are a consequence of emotion
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
DBT Skills Training Overview
Identity confusion
Core mindfulness skills
Distress tolerance
Emotional instability
Emotion regulation
Relationship problems Interpersonal effectiveness
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/
• One’s personal objectives (i.e., “wants”)
• A healthy relationship
• One’s self-respect
Interpersonal Effectiveness
Appear confident
Easy manner
Apologies (no undue)
Stick to values
Emotion Regulation
Involves managing emotions through:
• Identifying and labeling emotions
• Decreasing vulnerability to negative emotions
• Increasing positive emotions through behavioral
• Decreasing suffering through mindfulness of
• Changing emotions through opposite action
Distress Tolerance
Crisis Survival Skills
Improving the moment
Pros and cons
Distress Tolerance
Guidelines for Accepting Reality
Observing the breath
Awareness exercises
Radical acceptance
Turning the mind
A Definition of Mindfulness
Focusing attention
on one thing at a time,
in the moment,
• Is the opposite of being on automatic pilot.
• Is the opposite of multi-tasking.
• Is not pushing away from/suppressing an
• Is not clinging to an experience.
• Is related to, but not synonymous with,
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.
• Is the opposite of refusal to tolerate an
• 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
Outcomes Across Studies
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
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.,
• 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
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