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Foundations of Skills Training

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Chris Skidmore

on 26 October 2016

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Transcript of Foundations of Skills Training

Foundations of Dialectical Behavior Therapy
Christopher Skidmore, Ph.D.
Brief history of the development of DBT
Early CBT applications to borderline personality disorder
DBT theory of borderline personality disorder
Core approaches in DBT
Getting a new client oriented to DBT
More importantly, when you see, "borderline personality disorder" in someone's medical record, what are your initial reactions or expectations?
Even the Best
Evidence-Based Approaches
Did Not Work

Pharmacotherapy effects modest in magnitude (and complexity/ severity still required psychotherapy)
Prior to DBT: BPD was Poorly Treated
(and Poorly Understood)
Late 1970s: Linehan and colleagues found that standard CBT did not work well enough.

different view
of suicidal behavior, emotion dysregulation, and BPD was needed to drive the development of new, more effective interventions.
Biological problem
lies in the emotion regulation system (possibly due to genetics, intrauterine factors, traumatic events in early development that affect the brain, or some combination)
invalidating environment
punishes or neglects to take into account individuals' emotional vulnerability. Furthermore, it:

Invalidating Environment
Interacts with
Emotional Vulnerabilities
in BPD:

An important feature of DBT is the assumption that the
emotion regulation system
is disordered,
specific emotions (
or individuals
2. Severe emotion dysregulation is partly due to dysfunctional behavioral responses as

attempts to manage
the main symptoms or problems
Linehan (1997) also argued that individuals with BPD have extreme
emotional vulnerability
, including:
Slow return to emotional baseline

(persisting reactions/emotions, biased memory, biased interpretations)
Developing DBT
RCT; Chronically suicidal BPD patients (N=47) randomly assigned to 1 year of DBT or to treatment as usual (TAU) in community.
Clients receiving DBT, compared to TAU, were significantly less likely to drop out of therapy, were significantly less likely to engage in parasuicide, reported significantly fewer parasuicial behaviors and, when engaging in parasuicidal behaviors, had less medically severe behaviors.
Further, DBT clients were less likely to be hospitalized, had fewer days in the hospital, and had higher scores on global and social adjustment.
Results held even after researchers corrected for the amount of time spent in therapy.
Effectiveness of DBT:
A Sample of Published Results
Linehan and colleagues made significant modifications
to standard CBT (guided by Biosocial Theory) to create
DBT (Linehan, 1993), a more comprehensive program:
Validation and acceptance-based interventions added:
Taught clients that emotions and behaviors (even troublesome ones) were understandable in light of the challenges they faced.
Acceptance did not prevent a focus on change; it

Clients (then) taught how they must change if they want a life worth living. DBT skills were designed to help.
Dialectical strategies added:
Helped both therapist and client to balance validation and change, reduce extreme emotions, and avoid polarizing arguments.
See handouts for examples
Linehan, Armstrong, Suarez, Allmon & Heard, 1991 (later replicated by
Verheul, Van Den Bosch, Koeter, De Ridder, Stijnen & Van Den Brink, 2003)
Linehan, Comtois, Murray, Brown, Gallop, Heard, Korslund, Tutek, Reynolds, & Lindenboim (2006)
RCT; women with BPD (N=101) and at least two suicide attempts/self-injuries in past five years (at least one in past eight weeks); outpatient clinic and community practice.
1 year of DBT vs non-behavioral "treatment-by-experts" in community.
DBT clients were half as likely to attempt suicide and had lower medical risk across all attempts/acts.
DBT clients were significantly less likely to drop out.
DBT clients had significantly fewer psychiatric ER visits and hospitalizations for suicidal ideation.
***Clients in both conditions showed statistically significant improvement in depression, reasons for living, suicide ideation.
Koons, Robins, Tweed, Lynch, et al. (2001)
Small RCT; Women with BPD (N = 20) recruited from VA clinic; not required to have history of parasuicidal behavior. Randomly assigned to DBT versus TAU for six months of treatment (not 12).
DBT clients showed statistically greater reductions in suicidal ideation, depression, hopelessness, and anger compared to TAU.
Upon completion, 3 of 10 DBT Ss continued to meet criteria for BPD compared to 5 of 10 in TAU.
DBT Approaches in Action:
Originally created to treat individuals with
suicidal behavior and borderline personality disorder (BPD).

Targets for Next Time:
Assignment for next time: Think of a particular patient you have known that you think DBT would be good for.
How might you discuss DBT with her/him
More DBT in action
High chronicity and costs (hospitalizations, long treatment episodes)
High mortality rate (suicide and self-injury)
Very low quality of life (crises, isolation, medical problems)
But few (if any) psychotherapies with proven efficacy
Impossible to treat suicide attempts, urges to self-harm, urges to quit treatment, noncompliance AND to help clients learn and apply CBT skills.
Clients reinforced therapists for ineffective therapist behaviors while
effective behavior:
Exclusive focus on change felt invalidating to clients (who withdrew from treatment, acted out, or both).
1) To improve attitudes towards patients, and 2) To identify the skills and approaches that should be used in treatment to enhance outcomes.
3. Emotion is
and includes:
negative automatic thoughts
, neurologic and physiologic processes, facial and muscle reactions, extreme
behavioral urges
, and emotion-linked actions or habits.
Heightened emotional sensitivity
(hypersensitivity to emotional cues, especially negative ones; tendency to react quickly; low threshold for extreme reactions)
Inability to regulate intense emotional responses
(extreme reactions to emotional stimuli, disrupted cognitive processing and self soothing)
BPD was re-conceptualized as a disorder of severe emotion dysregulation that develops due to interactions between


biological problem

and an
invalidating environment
1) the understandable results of extreme emotions, or
The treatment was designed to target problematic
(rather than to "fix problematic patients").
The severe, problematic
behavior patterns of BPD were organized into a hierarchy to guide what to target (and when) in DBT:
Quality-of-Life Interfering Behaviors
(other skills deficits, environmental problems, other life problems)
Life Interfering Behaviors
(suicidality, self-harm, behavioral and emotional crises)
Therapy Interfering Behaviors
(motivational deficits, problems in the therapy relationship, avoidance of sessions or assignments)
Recognize Standard Assumptions and Components of CBT:
The mind (and thoughts, specifically) as both the problem and the solution
Exploring connections among thoughts, behaviors, and emotions
A clear
and flexible
plan for how therapy proceeds
Evaluation/testing of the treatment in clinical trials
Specific goals and cognitive/behavioral targets for change
What have you heard about DBT?
Provider burnout, frustration, compassion fatigue
The Biosocial Theory of BPD
(Linehan, 1997):
5. Does not teach a child how to solve problems that cause strong emotions (or actively punishes problem-solving)
4. Encourages rapidly switching between emotional extremes
3. Does not teach a child how to understand, label, regulate, or tolerate emotional experiences (or actively punishes these skills)
1. Communicates that emotions/emotional displays are bad
2. Reinforces extreme expressions of emotion (e.g., a child only gets attention through an extreme emotional display)
Thus, Biosocial Theory offered a
, non-blaming view of the symptoms and behaviors of individuals with BPD.
1) Describe the theoretical and empirical foundations of DBT
2) List core approaches in DBT
3) Identify core approaches used in a demonstration
Cognitive-Behavioral Therapy Didactics Series, October 2016
When was the last time you felt that way?
Linehan, M. L. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guildford Press.

Linehan, M. L. (2015). DBT skills training handouts and worksheets. New York: Guildford Press.



(and unique features of DBT, too)
client-therapist relationship
What are the hallmark symptoms of BPD?
What would be your initial treatment plan for a patient with BPD?
What Do You Already Know about DBT?
2) their best-available attempts to re-regulate out of control emotions
All problematic behaviors of individuals with BPD are either:
Newer applications of DBT
The critical roles of the Team and different Team members
Dive deeper into specific DBT components and interventions
Practicing Validation:
seeing and identifying patient strengths and valid aspects of their points of view (even if you disagree or are concerned).
Try to generate a
response to the following patient statements (not a response focused on change or problem-solving, just one focused on validating the concerns or the client).
"I stopped taking all of my medications because I'm sick of all the side effects. You're just making me worse."
"I'm cutting again because there's no point. It's hopeless."
Who Am I?
What Are You Hoping to Learn Today?
Getting a New Client Motivated for DBT (While Assessing and Targeting Suicidality)
See also the chapter on validation and the handouts on different
levels of validation
Three core problems (among many):
- They “rewarded” the therapist with warmth/engagement if allowed to change the discussion or if therapists stopped pushing for change when clients withdrew or threatened self-harm.
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