Mindfulness and Acceptance in DBT Skills Training Catherine R. Barber, Ph.D. Baylor College of Medicine DBT Associates of Greater Houston I am delighted to talk with you today about the Skills Training mode in Dialectical Behavior Therapy and more specifically about the concepts of mindfulness and acceptance as they apply to skills training. I hope to provide you with an introduction to—or perhaps, in some cases, a review of—several aspects of DBT. Although my talk should not be viewed as a substitute for reading Linehan’s skills training manual, nor will it fully prepare you to lead a skills training group, it will hopefully whet your appetite to learn more about this fascinating and highly effective treatment for Borderline Personality Disorder. At the very least, I hope that you will come away from this talk with increased confidence in any referrals you might make to a DBT program.

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. There are several objectives for this talk, and we’ll only be able to touch on these topics with limited detail. [Review objectives.] To demonstrate how skills training is conducted, I have modeled this talk after a typical skills training group, using the same format and techniques that I would use in group. Note that a skills training group is much more like a class or seminar, rather than a process group. Whatever the therapists know, they share with the group.

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

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. Linehan developed the biosocial theory of BPD to account for both clinical observations commonly made about patients with BPD and research findings on the origin of BPD. She noted that BPD is primarily a disorder of emotion regulation. There are two primary contributions to the development of BPD. The first of these is emotional vulnerability, which is a biologically-based predisposition to three qualities: emotional sensitivity (reacting more quickly to emotional stimuli), emotional intensity (reacting more strongly to emotional stimuli), and slow return to emotional baseline. The second contribution is the invalidating environment. An invalidating environment negates, dismisses, or ignores an individual’s personal preferences and experiences. An invalidating environment may tell a person not to feel or think a certain way, may overlook the person’s opinions and wishes, and does not convey comprehension of the person’s behavior, particularly when the behavior is freely emitted (as opposed to elicited by environmental stimuli). Abuse is a severe version of invalidation—and indeed, a high percentage of people with BPD report a history of childhood abuse. However, much more subtle forms of invalidation are more common. It’s important to note that invalidation is quite common, and most people are fairly resilient. However, the interplay between repeated invalidation and an a sensitive temperament appears to be pathogenic for BPD. Note that this is a transactional model, not an additive model. The child’s behavior (influenced by his or her emotional vulnerability) elicits invalidation. And invalidation fuels emotional vulnerability. According to the theory all BPD symptoms are either a consequence of emotion dysregulation or else are efforts to regulate. Example: interpersonal chaos; self-injury; extreme anger.

The DBT Framework Theoretical foundations: Cognitive-behavioral therapy Dialectical theory Zen philosophy DBT has three theoretical foundations. The “brains” of DBT is cognitive-behavioral therapy. The technology of change is critical for treating BPD, as many of the behaviors associated with this diagnosis are life-threatening and often threaten to destroy the therapy as well. Strategies such as problem-solving, contingency management, and cognitive restructuring are a huge part of what DBT practitioners use to effect change. In fact, DBT is more behavioral than many other cognitive-behavioral treatments. The “heart” of DBT is dialectical theory, which introduces the idea that the truth is constantly evolving. Each person’s perspective contains some truth, but no one perspective contains the entire truth. Furthermore, the dialectical concept of balance or synthesis is crucial to DBT. Efforts to elicit change from patients must be balanced with validation of patients’ suffering and acceptance of them exactly as they are in the moment. The “gut” or “soul” of DBT is Zen philosophy. Keep in mind that Zen is [something about religion here]**. The concepts of mindfulness and acceptance are common in contemplative practices across spiritual traditions, yet they are also accessible to people who do not identify themselves as spiritual or religious. Zen practices provide patients with tools to achieve the calmer, wiser state of mind that is necessary for emotion regulation. Furthermore, the Zen concept of “walking the middle path” fits nicely with dialectical theory.

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 DBT has five functions, or goals. These are typically achieved through the modes used in standard, comprehensive DBT. The first function is to enhance patient capabilities. This typically takes place in the mode of skills training, though of course individual therapy also focuses on strengthening skills learned in skills training group. The second function is to improve patient motivation, which is mostly the purview of the individual therapy mode. The third function is to generalize learning to all relevant contexts. New capabilities are only useful if they can be employed when necessary. Although it is gratifying when patients act skillfully in session, skills are needed in the remaining 167 hours of the week! The typical mode for generalizing skills is phone coaching. The fourth function is to structure the environment—both the patient’s environment and the treatment environment. Typical modes include case management, family work, and program structuring. The fifth function is to enhance therapist capabilities and motivation to work with BPD patients. One of the assumptions of DBT is that therapists need support. The mode of consultation team provides “therapy for the therapist.”

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 Linehan has identified four stages of treatment relevant to patients with BPD. Prior to starting treatment, patients are considered in “pre-DBT.” The goals of this stage are orienting and commitment. Following the pre-DBT stage, most of the more severe patients begin at Level 1. The primary problem of level 1 is severe behavioral dyscontrol. The goal is behavioral control. Level 2 problems are related to chronic, traumatic stress. Many survivors of chronic abuse and other traumas develop emotional avoidance. Any unpleasant emotions are avoided at all costs, due to the extreme negative arousal that they produce. The goal of Level 2 is non-anguished emotional experiencing—being able to experiencing emotions without extreme distress. Level 3 is where most of us are most of the time. We experience happiness and unhappiness. There are problems to be solved, conflicts to be addressed. The goals of level 3 is to increase mastery, further improve relationships, and learn to live with upsets and disappointments. Level 4 is somewhat more esoteric and involves the problem of lack of self-actualization. The goal is to develop enhanced capacity for joy and freedom through detachment.

The DBT Framework Stage 1 Target Hierarchy: Decrease life-threatening behaviors Decrease therapy-interfering behaviors Decrease quality of life-interfering behaviors Increase behavioral skills Given that most patients start at Stage 1, most of the writing and research have been done on this stage. The targets of stage 1 individual therapy are, in order: Decreasing life-threatening behaviors, including suicide and self-injury. Decreasing therapy-interfering behaviors of the patient AND the therapist, including missing sessions, coming late, not doing homework, calling excessively, etc. (on the part of the patient) and inattentiveness, sarcasm, lateness, having a judgmental stance, getting off-track, etc. (on the part of the therapist). Decreasing QoL-interfering behaviors, including substance use, disordered eating, poor self-care, depression- and anxiety-related behaviors, work/school dysfunction, interpersonal chaos, etc. Increase behavioral skills, including mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and self-management.

DBT Skills Training Overview Skills Training Target Hierarchy: Reduce therapy-destroying behaviors Increase skill acquisition and strengthen skills Reduce therapy-interfering behaviors The targets of stage 1 skills training are: Reduce therapy-destroying behaviors, including violent behavior in group, verbal attacks, suicidal or self-injurious behaviors, yelling or loud crying that distracts the group, etc. Anything that is so serious that group cannot function would fall in this category; however, the bar should be set fairly high. Increase skill acquisition and strengthen skills: The vast majority of the time is devoted to this target. Even when highly problematic behavior is occurring, the best strategy is often to ignore the behavior and continue to teach the skills, at least until the break. Reduce therapy-interfering behaviors: These are generally targeted for extinction by ignoring, though sometimes the therapist may comment on the behavior in such a way as to suggest the desirability of change while not spending any significant time on it. At times, the therapist may instruct patients engaging in these behaviors to apply skills to the problem at hand.

DBT 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 The categories of problems in BPD include: ***

Core Mindfulness Skills States of Mind Emotion mind Reasonable mind Wise mind In DBT, mindfulness is considered a “core” skill, running through all the other skills. We all have three states of mind, any one of which can be more dominant at any point. The first state is emotion mind. This is the state of mind in which we are governed by our feelings, preferences, and opinions. Creativity, compassion, spontaneity, and excitement come from this stage, as do anger, sadness, fear, shame, and guilt. Taken to the extreme, emotion mind can lead to impulsivity, thinking errors, chaotic interpersonal relationships, and other problematic outcomes. Reasonable mind is the state in which we are governed by logic and the facts. It is analytical, cool, and methodical. Our ability to plan ahead, to delay gratification, and to inhibit emotional displays comes from reasonable mind. However, when taken to the extreme, reasonable mind is rigid, cold, and unempathic. Rumination can arise from being too analytical. Finally, wise mind is the integration or synthesis of emotion and reasonable mind. Rather than just thinking or feeling, it the source of knowing something in your instinct or gut. Wise mind considers and weighs both the facts and your feelings, but it goes beyond that. It is centered, peaceful, and experiential. Thus, if someone is experiencing an intense emotion, they are probably not in wise mind. Wise mind is the source of mindfulness.

Core Mindfulness Skills “What” Skills Observe Describe Participate “How” Skills Non-judgmentally One-mindfully Effectively In DBT, mindfulness skills are divided into “what” to do and “how” to do it. The “what” skills involve first observing an experiencing—just noticing with the 5 senses, without putting your experience into words just yet. We sometimes call this skill “teflon mind,” meaning that thoughts and feelings make contact but don’t stick. Second, describe the experience in words. Stick to the facts. Describe what you see, hear, smell, taste, touch, feel, think, do. Third, participate in life fully and without self-consciousness. Throw yourself into an activity. Make wise decisions. Practice skills. The “how” skills include nonjudgmentally—that is, without labeling an experience as “good” or “bad.” It involves sticking to the facts. One-mindfully involves doing one thing at a time. If attention wanders, bring it back to your focus. Effectively means doing what works. It involves playing by the rules, even when you don’t like the rules. Being effective is the same as being skilled.

Interpersonal Effectiveness Involves the balancing act of obtaining/ maintaining: One’s personal objectives (i.e., “wants”) A healthy relationship One’s self-respect The next skill module focuses on improving relationship behaviors. There are three main goals: obtaining things that you want, getting or maintaining a health relationship, and improving or maintaining self-respect. Ideally, all three goals can be achieved. However, sometimes certain goals have to be prioritized over others. The skills focus on how to set these priorities (e.g., do I press to get what I want, or do I back off to save the relationship?) and how to achieve each goal.

Interpersonal Effectiveness Describe Express Assert Reinforce Mindfully Appear confident Negotiate Gentle Interested Validate Easy manner Fair Apologies (no undue) Stick to values Truthful We teach basic assertiveness skills for the first goal (getting what you want). We teach empathy and validation skills for the second goal (healthy relationship). And we teach self-esteem skills for the third goal (self-respect). Acronyms make the skills easier to remember.

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 The next skill module focuses on regulating or managing emotions, primarily through change strategies but also through mindfulness strategies. Vulnerability: PLEASE MASTER Opposite action (aka, exposure): For “unjustified” emotions. Sadness: get active (don’t isolate) Anxiety: approach (don’t avoid) Anger: gently avoid or do something nice (don’t attack) Guilt: make amends (if justified); repeat behavior (if unjustified)

Distress Tolerance Crisis Survival Skills Distraction Self-soothing Improving the moment Pros and cons Two types of distress tolerance skills: Short term strategies for getting through a crisis without making it worse, and acceptance of reality to tolerate things that can’t be changed. Crisis survival skills focus on distraction, soothing with the five senses, doing something in the moment to make that moment less painful, and evaluating the pros and cons of acting skillfully vs doing an old, unskillful behavior. Remember: These are short-term strategies to take the place of harmful behaviors, like substance use, self-harm, etc. They are not necessarily guaranteed to improve mood (though sometimes they do have that effect). The goal is to get through a crisis until either problem solving strategies can be applied or until you determine that acceptance is required.

Distress Tolerance Guidelines for Accepting Reality Observing the breath Half-smile Awareness exercises Radical acceptance Turning the mind Willingness Guidelines for accepting reality provide balance to the “change” side of distress tolerance. All of these exercises and principles focus on using wise mind to get through situations that one cannot change. Observing the breath: Focusing on the breath has a centering effect. It is intended to help people tolerate themselves, the world, and reality, just as it is. These exercises include deep breathing, measuring your breath by your footsteps, counting breaths, following the breath while listening to music or while carrying on a conversation. Half-smile: Our facial expression has an impact on our emotions. Adopting a serene, pleasant facial expression can facilitate feelings of calm and acceptance. Practice half-smile first thing in the morning, during free moments, when irritated, while contemplating people you don’t like! Awareness: In the middle of a crisis, it can be grounding to turn attention to the positions of the body, activities, that one is doing, and even connections to the universe! Radical acceptance is a principle: It is letting go of fighting reality, insisting that things “ought” to be a different way, and refusing to move past what cannot be changed. Pain is part of living; it’s a signal that something is wrong or that something needs to be done. We have to be aware of and accept pain before trying to change it. Suffering is pain plus non-acceptance. Turning the mind involves recommitting to acceptance over and over again. Willingness is accepting and responding to what is in an effective way. Not sitting on one’s hands, trying to fix things that can’t be fixed, or refusing to fix what can be fixed.

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

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. Clinging: “Thank you for sharing, now let’s move on.” Mindfulness is related on mentalizing insomuch as mindfulness is usually a pre-requisite for mentalizing. We must be aware and attuned in order to “read” other people and understand both their actions and ours in terms of mental states. It is very difficult to do this—perhaps even impossible—when on automatic pilot or in a fog. Indeed, we tend to turn toward heuristic biases when operating on automatic pilot, and these biases may not help us to mentalize accurately. However, mindfulness is distinct from mentalizing. In an excellent paper by Choi-Kain and Gunderson (2008), mentalizing is differentiated from a number of other constructs, including mindfulness. They write, “Both mindfulness and mentalization involve directing one’s attention to one’s own experience as a way to mitigate tendencies toward impulsivity and reactivity. Both also emphasize the integration of cognitive and affective aspects of mental states in encouraging simultaneous recognition and participation in internal experience. Mindfulness only overlaps with one of the two modes (explicit) and one of the two objects (self) within the mentalization concept. Three other distinctions exist between the two concepts. First, in mindfulness, one’s own experience interacting with inanimate objects, and not just other people, is considered. Second, the practice of mindfulness is oriented to present experience, while the process of mentalization can concern the past, present, and future. Finally, mindfulness aims at acceptance of internal experience, whereas mentalization emphasizes the construction of representation and meaning related to these experiences.”

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 Note that other psychotherapeutic models include aspects of mindfulness, including thought records, behavioral diaries, free association, and reflective responding. Metaphors: An excellent way of making this concept more tangible, metaphors and stories are encouraged when teaching about mindfulness and before practicing mindfulness.

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

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. As discussed, acceptance requires tolerance of experience, no matter how unpleasant. It is important to note that acceptance does not mean that problem-solving and change are abandoned. What is accepted today might be the focus of change tomorrow. What has happened in the past cannot be changed, but behaviors in the future can be changed to reduce the likelihood of unwanted outcomes. Acceptance is radical: ALL of reality must be accepted. Zen practice suggests that this one moment is only as it can be, given the unique set of factors and circumstances that led up to it. That is not to say that the future is predetermined. However, if we had perfect, 20-20 hindsight, we would be able to see exactly how each moment in the past arose. Acceptance provides the necessary balancing force to change. It validates experience, thoughts, feelings, actions, and even the self as true and understandable.

Acceptance in Practice Being a “gracious host” Turning the mind Awareness exercises Effective decision-making Metaphors for acceptance One of my favorite analogies for acceptance is that of being a gracious host who has unexpected (or even unwanted) guests. The effective thing to do is to welcome the guests in, treat them well (but not indulge them), and then turn attention elsewhere. You are still aware of their presence, but you are not ruled by your feelings about them. They become part of the crowd, not dominant. Effectiveness: Doing what works REQUIRES acceptance of reality. If a person clings to some alternative reality (e.g., “perfect world” or “the way things should be”), she is unlikely to play by the rules of the current reality. Lots of metaphors for acceptance exist: A great one is of the man who had dandelions.

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 One way for therapists to model acceptance is through validation strategies. These range from the most basic to the most complex. Staying awake Accurate reflection: Mirroring Articulating the unspoken: Inferring meaning, thoughts, emotions, etc. Validating – past: linking current behavior with past events Validating – current: linking current behavior with current events Radical genuineness: Being the same with patients as one would be with others.

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., 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 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 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