Burkhard Dafert
- Theory
Dialectical Behavioral Therapy, or DBT for short, and one of its central therapy components, skill training, can be traced back to Marsha M. Linehan. Originally developed to treat chronic suicidality, DBT emerged as a highly effective form of intervention in the psychotherapeutic treatment of borderline-type emotionally unstable personality disorder. After extensions and modifications, this form of intervention is now applied to all mental disorders where problems with affect and emotion regulation and impulse control play a significant role.
With regard to the genesis of mental disorders, skill training is based on the bio – psycho – social model. In addition to genetic dispositions and physical changes, the importance of the invalidating environment for the development of dysfunctional behavior is particularly emphasized. In an invalidating environment, self-determined behavior or communications of personal emotional experiences are not encouraged, but criticized, labeled as socially intolerable, and in the worst cases pathologized or directly punished. The individual does not learn to develop confidence in his or her own emotions and cognitions as adequate responses to events in such an invalidating environment. Therefore, they fail to name emotions and develop effective emotion modulation skills and thus efficient tension regulation.
Skill training combines approaches from classical and cognitive behavioral therapy, mindfulness-based approaches, and body-oriented techniques. For the practitioner, knowledge of clinical symptomatology, knowledge of biological factors and psychosocial relationships, as well as the consequences of traumatic experiences, knowledge of attachment theories, and knowledge of the development of dysfunctional schemas and relationship patterns are essential. With this knowledge, the underlying disorders can be understood and appropriate skills can be selected.
Skill training is composed of 5 modules: Mindfulness, Emotion Modulation, Stress Tolerance, Interpersonal Skills, and Self-Esteem. The module self-esteem is not present as a separate module in the original version of Linehan’s skill training (cf. Linehan 2015), but is listed as such by default in German-speaking countries. In terms of content, the self-esteem module is based on the program for building self-esteem according to Potreck – Rose and Jacob (Potreck – Rose & Jacob, 2015).
- Fields of application
As mentioned above, skill training can be useful in all mental disorders where problems in the area of emotion modulation and tension regulation are at the forefront. There are separate skills training programs for BPD, PTSD, addiction, eating disorders, the forensic field, the educational field, and for working with adolescents, among many other areas.
Originally intended to be just one of the 4 basic building blocks of DBT, individual therapy, skill training, telephone contacts, and supervision for the treatment provider, skill training is now also used in combination with other therapy methods or as skill training alone, especially in residential treatment. Skill training can be used both as group training and in individual settings. The teaching of all 5 modules is recommended, but it is also possible to deviate from this standard form and only teach individual modules of the training, or individual sections of modules. In order to speak of skill training, aspects of mindfulness, stress tolerance and emotion modulation must be taught in any case.
- Practical application
Skill training is intended to make patients aware of existing skills on the one hand, and to learn and train new skills on the other. Through progressive conscious integration of the skills into the patient’s behavioral repertoire, automated application in crisis situations should be achieved.
This is done by imparting theoretical knowledge about the development and maintenance of problem behavior and mental disorders, practical exercises and exchange of experiences.
What are skills?
M. Linehan defines “skills” as cognitive, emotional, and action responses that lead to maximum positive and minimum negative outcomes in both the short and long term. These responses may be automated or consciously employed (Linehan 1996b).
By means of skills, we can specifically control our thinking and our behavior. The patient should learn to navigate through crises with brief concise self-instructions without resorting to self-harming behaviors. Skills thus serve to cope with acute crisis situations as well as to cope with everyday life. In the short term, skills can replace inappropriate patterns of perception, feeling, or behavior. In the long term, skills can be used to modify views and patterns of interpretation towards oneself and the environment.
Trainer behavior
The trainer is guided by the basic dialectical approach common in DBT. He tries to maintain a balance between acceptance and change, between validating and demanding interventions.
Training Tasks
In addition to acquiring and reinforcing skills during training, working with training or homework assignments ensures generalization of newly acquired skills. Only skills that have been sufficiently trained are available in the event of a crisis. The principle applies that all skills must be practiced under NON – stress conditions. This is done under the motto “The fire department does not practice in case of fire!”.
Treatment contract
The treatment contract is an important component of skills training. In this contract, the client commits to practice the skills learned and to work on reducing the defined problem behavior. The trainer commits to further training and compliance with the agreed framework conditions. Other possible contents of the treatment contract can be found in the following list:
- Duration
- Presence
- Conditions of participation
- Punctuality
- Homework
- Contacts outside the group
- Dealing with self-injury
- Leaving the group during the session
- Dealing with suicidal intent or endangerment
- No pairs
- Secrecy / Confidentiality
- Alcohol / Drugs
- Time out – regulation
Module 1: Mindfulness
The aim of this module is to train non-judgmental perception and focus on the moment. Mindfulness offers the opportunity to recognize and modify self-regulatory processes. The interruption of routines in information processing enables re-evaluations and, subsequently, a reduction of avoidance behavior occurs. In a state of mindfulness, dysfunctional basic assumptions can be more easily recognized and changed. This “satellite position” to one’s own self and one’s own cognitive processes is a basic prerequisite for many other skills. That’s why the Mindfulness module is at the beginning of the skills training. Mindfulness, the mother of all skills, is therefore on the one hand the goal of the skills training, and on the other hand also a prerequisite for all other modules.
Mindfulness is understood as a skill that can be learned and trained. In skill training, a distinction is made between the “what – skills” and the “how – skills”. The “what – skills” are perceiving, describing and participating. The “how – skills” are adopting a non-judgmental attitude, focusing on the moment, and acting effectively.
Through regular training of the “what – and how – skills”, the state of mind of intuitive knowledge is to be achieved. This intuitive knowledge is the synthesis of the rational state of mind, where intellect and logic predominate, and the emotional state of mind, where emotions and moods are prominent.
Module 2: Stress tolerance
“Stress tolerance is the ability to endure and survive crises without making things worse” (Linehan 2016, p. 320).
The stress tolerance module is divided into 2 sections: In the first part, skills are taught for coping with acute crises and the aversive high-stress states or dissociative states that occur. The patient should learn to replace the previously used self-harming behaviors with less self-harming behaviors. In high-stress situations, the normal pathway of arousal conduction via the hippocampus and cortex is disrupted or, as in the case of dissociation, almost completely blocked (Sendera, 2010). This results in a limitation of cognitive skills. By setting intense sensory stimuli, this blockade can be broken and the ability to act can be restored. The patient learns this breakthrough by acquiring skill chains. Skill chains are understood to be a constant sequence of skills that are trained by the patient under “non-stress conditions” with the aim of remaining capable of acting even in the event of a crisis. Skill chains often begin with the setting of an intense sensory stimulus. This can be a pain stimulus, a cold stimulus, but also an intense smell or taste sensation. The availability of the stimulus in the crisis situation is important. The patient is therefore encouraged to carry a selection of sensory stimuli in an “emergency kit” at all times. In second place, the skill chain includes reality checking strategies. This is followed by skills for emotion regulation or even strategies for distraction, calming down or improving the moment. On the one hand, the use of stress tolerance skills ensures that tension is reduced to a tolerable level; on the other hand, many skills from other modules can only be used meaningfully once cognitive performance has been restored.
The second part is about teaching skills that will help patients in general living. In addition to teaching patients to be willing to explore new avenues, strategies are developed with them to shape their lives in a way that emphasizes purposeful action. The patient learns to differentiate between changeable life circumstances and unchangeable environmental conditions that must be accepted. Skill training teaches strategies on how to manage change efficiently. Patients are often preoccupied with the mental search for optimal solutions that are not feasible under real, constrained conditions, which often leads to inactivity and passivity. In skill training, changeable problems focus on the next possible step that will bring the patient closer to goal achievement, resulting in an increase in activity and the patient’s experience of self-efficacy. In skill training, the patient learns to face the unchangeable circumstances with a mindful, accepting basic attitude, whereby this acceptance must not be confused with approval of an unjust and painful reality.
Emotion Modulation Module
This module is the core of the skills training.
In skill training, the evolutionary value of emotions is assumed. Emotions are automatic response patterns to external and internal stimuli that ensure rapid action. In the course of evolution, these reaction patterns have developed because they ensured survival or were useful for recurring problem solving. These emotions are represented as an emotional network. This network includes perception, thinking, physical or physiological responses, and calls to action. Emotion modulation means the ability to control the intensity of emotional response by influencing the components of the emotional network.
In skill training, the patient learns to recognize and differentiate individual emotions based on the various components of the emotional network. Emotions can be specifically influenced by means of targeted management and control of action intentions, body posture and physical reactions, as well as changes in interpretation patterns and cognitive processes.
Further focal points of this module are the recognition of emotion-typical trigger situations and antecedent and subsequent emotions typical for the respective emotion, as well as the teaching of skills to reduce emotional vulnerability. Identifying and changing dysfunctional basic assumptions about emotions and emotion modulation complement the Emotion Modulation module.
Module 3: Interpersonal skills
In this module, the client learns to deal with interpersonal conflicts without jeopardizing the relationship with the other person and without losing self-respect. He should be able to insist on his own wishes, goals and opinions and be able to control the intensity of his reaction. Skills for verbal and non-verbal communication complete this module.
Describing behavioral skills and sequences of actions does not yet necessarily mean that these skills can be applied in real social situations. Role play is therefore one of the primary methods of knowledge transfer in this module.
Module 4: Self-esteem
Three core areas can be distinguished in this module: Building realistic positive self-esteem, identifying and changing dysfunctional basic assumptions about oneself, and building self-caring behaviors.
The development of a positive self-esteem takes place on the one hand through the expansion of competencies, the promotion of pleasant experiences with one’s own position, and the recognition and change of dysfunctional evaluations (Bohus & Wolf, 2009,p. 320). The processing of dysfunctional basic assumptions is based on the rules of cognitive restructuring. Dysfunctional basic assumptions are named, changed and replaced by more functional assumptions. These functional assumptions are then tested in the behavioral experiment. Building self-care behaviors includes making lists of enjoyable activities, as well as developing a fair view toward oneself and one’s actions.
- Evidence
Randomized controlled trials have demonstrated positive effects in the areas of emotional dysregulation, affective instability, and interpersonal skills. Skill training proved effective for PTSD, depression, addiction, and eating disorders. For a review of the current state of research on the effectiveness of skills training, see Linehan 2017.
Literature:
Bohus, M & Wolf, M. (2009) Interactive skills training for borderline patients. Stuttgart, New York: Schattauer
Linehan, M. (1996) Dialectical-behavioral therapy of borderline personality disorder . Munich: CIP Media
Linehan, M. (1996) Training Manual for DBT of the Borderline. PS Munich: CIP Media
Linehan, M. (2017) Handbook of Dialectical – Behavioral Therapy Volume 1: DBT Skills Training Manual. Munich: CIP Media
Linehan, M. (2017) Handbook of Dialectical – Behavioral Therapy Volume 2: Workbook for therapists and patients. Munich: CIP Media
Potreck-Rose, F. & Jacob, G. (2006). Self-appreciation, self-acceptance, self-confidence. Psychotherapeutic interventions to build self-esteem.. Stuttgart: Klett-Cotta.
Sendera, A. & Sendera, M. (2005/2007/2012) Skills training in borderline and post-traumatic stress disorder. Vienna: Springer
Sendera, A. & Sendera, M. (2010). Borderline – the other way of feeling. Understanding and living relationships. Vienna: Springer
