Integrating DBT Group Training Skills to Other Approaches

Group training skills in dialectical behaviour therapy can be applied in the treatment of numerous client presentations, and integrated with other therapeutic approaches.

Introduction

When Marsha Linehan developed dialectical behaviour therapy in the 1980s to meet the needs of her seriously unwell borderline personality disorder clients, she expressly proposed a multi-component framework wherein each element of treatment responded to an aspect of the clients’ or therapists’ needs. This clear articulation led not only to the empirically validated success of DBT, but also to the broadening utilisation of DBT for other than BPD clients (Miller & Rathus, 2000; MacPherson, Cheavens, & Fristad, 2013). In this article, we explain which skills categories comprise the group skills training component and offer a perspective on why they may provide a useful framework for therapists working in other modalities, with other presenting issues. First, an outline of the larger picture of which the group training skills are a part.

The treatment modalities of DBT

There are four primary modalities of treatment, or components, in DBT:

• Therapist consultation groups
• Individual therapy
• Telephone contact/crisis coaching
• Group skills training (MacPherson et al, 2013; Miller, Rathus, & Linehan, 2017; Harvey & Rathbone, 2013).

Not all DBT or DBT-informed programs carry all four modes of treatment. Therapists working in a solo practice may not have access to a therapist consultation group, except as that occurs in their regular supervision meetings. Similarly, not all therapists allow wide access by telephone between sessions. Finally, most modalities designed around individual therapy are unlikely to have group skills training unless that is part of a broader treatment plan, such as with substance abuse or eating disorder issues. What we focus on here is the last component, group skills training, highlighting how the major thrusts in the category have applicability to a wide range of client presentations.

Group skills training

In DBT, group skills training sessions, which are not group psychotherapy sessions, allow DBT therapists to teach skills that can help people deal with life situations more effectively. Ideally, these skills are conducted by a different therapist than the “primary therapist” with whom the client is having individual sessions. The skills taught are comprised of four modules or clusters of skills which are recognised as being particularly relevant to BPD clients (a fifth skills module, “Walking the middle path”, was added by Harvey and Rathbone, 2013, in their work with adolescents. For details, see the Mental Health Academy courses Dialectical Behaviour Therapy for At-risk and Suicidal Adolescents and Dialectical Behaviour Therapy for At-risk and Suicidal Adolescents: Specific Considerations). The four categories (not including the extra adolescent module) are:

1. Mindfulness skills
2. Interpersonal effectiveness skills
3. Emotional regulation
4. Distress tolerance techniques (Grohol, 2019; Harvey & Rathbone, 2013)

Mindfulness skills

Derived from certain techniques of Buddhist and other Eastern spiritual practices, mindfulness skills are psychological and behavioural versions of meditation practices which do not involve any religious allegiance to apply them. Essentially, they are techniques to enable the practitioner (the BPD client) to become more aware of the contents of experience, and to develop the ability to stay with that experience in the present moment. Note that, in the years since Linehan began recommending that mindfulness skills be taught to clients, the use of them in many therapeutic environments – and many other disciplines as well – has burgeoned exponentially, with new research findings coming onstream regularly to validate the effectiveness of mindfulness practice for health at all levels (Bernardez et al, 2023; Goldberg et al, 2023).

Here we note how both depression and anxiety are common conditions that take a person out of the present moment, into either a regretted past or a feared future. Those struggling with low self-esteem find that the newfound ability to stay mindful can help alleviate feelings of distress about imagined inadequacy. The added calmness can help clients move toward more realistic interpretations of their own strengths and possibilities.

As part of mindfulness, DBT holds that there are three primary states of mind, which together pose and resolve the dialectical dilemma that we discussed in this article:

• Reasonable Mind, which a person is in when she approaches information and knowledge intellectually;
• Emotion Mind, the opposite of Reasonable Mind, when her thinking and behaviour are controlled primarily by her current emotional state; and
• Wise Mind, when a person has integrated emotional experience and logical analysis and added intuitive knowledge (Linehan, 1993; Pederson, 2017; Long, 2011).

The chart below helps clients to understand the dialectical resolution between Reasonable Mind and Emotion Mind which results in the integrated Wise Mind:

(Vivyan, 2018)

Interpersonal effectiveness skills

The response patterns taught in DBT skills training focus on effective ways of achieving one’s objectives with other people; they are like many assertiveness and interpersonal problem-solving classes. These include acquiring effective strategies for coping with conflict, asking to have one’s needs met, and saying no. Mental health experts writing about BPD often comment how the BPD-diagnosed individual will possess a general knowledge of the skill sets; the problem comes when they try to apply it. They may be able to name all the steps in a behaviour sequence for someone else with a problem but will completely be incapable of generating the same behaviour sequence for their own similar problem.

Accordingly, the module focuses on situations where the objective is to change something (that is: request that someone do something) or to resist change happening (that is: say no). The skills taught are designed to maximise the client’s chances of getting their needs met without damaging either their self-esteem or her relationship with another person. Thus, they teach clients to do several things, all of which are particularly helpful for those with high emotional dysregulation:

• To balance their needs with the needs of others
• To get their requests, or refusal of requests, taken seriously
• To respond in respectful ways to the other person
• To respond to others in ways that maintain and increase their self-respect (Long, 2011; Harvey & Rathbone, 2013)

From narcissism to co-dependence to substance abuse and eating disorder issues, most clients that make their way to therapy rooms have experienced some degree of relational failure, whether through challenges to set boundaries and make their own needs known, or through running roughshod over others’ needs due to their condition (such as substance misuse clients, who have racked up many a breakup as a result of being “absent” or even abusive through being high or drunk). Interpersonal skills are basic grist for the mill of attaining a high-quality life.

Emotion regulation

BPD-diagnosed clients and those who are suicidal tend to be emotionally intense and unstable. Mood can range from depressed or anxious to angry or intensely frustrated, so an important aspect of the healing is to learn to regulate their emotions to change from distressing emotional states. DBT skills for emotional modulation include:

• What emotions are, where they come from, and why they have them
• Identifying and labelling emotions
• How to manage the urges that are part of emotions
• Identifying obstacles to changing emotions
• Reducing vulnerability to emotional dysregulation
• Increasing positive emotional events
• Increasing mindfulness to current emotions
• Taking opposite action
• Applying distress tolerance techniques (below) (Harvey & Rathbone, 2013; Linehan, 1993).

It is not an overstatement to say that emotional regulation is likely at the base of most mental health issues. A meta-analysis examining the relationship between emotion regulation and mental wellbeing in patients with mental disorders found that overall deficits in emotion regulation showed a negative moderate correlation with well-being (r = −0.47). The researchers concluded that:

“. . . emotion regulation is not merely related with psychopathology, but also with well-being in general. . .. Therefore, it might also be important to improve emotion regulation when aiming to improve well-being in people with mental disorders” (Kraiss, ten Klooster, Moskowitz, & Bohlmeijer, 2020).

Distress tolerance techniques

In teaching participants how to deal with crises in a more effective way, without having to resort to self-harm or other problematic behaviours, distress tolerance skills have the objective of showing people how to bear pain and distress skilfully. It should be noted that many current approaches to mental health treatment focus on changing distressing events and situations rather than on accepting them. Psychodynamic, psychoanalytic, gestalt, and narrative therapies, conversely, have equipped clients working in them to accept and tolerate distress, often through finding meaning in it. We note here that clients do not usually (willingly) come to therapy unless they are in distress, so although they need skills and insight to change the long-term trajectory of their issues, they also need skills for immediate relief to get through tough moments when problem-solving is not possible. In this, such skills are a universal need for clients.

Distress tolerance skills have to do with the ability to accept both oneself and the situation without judgment or evaluation. This does not mean that the client must approve of a given situation; acceptance of reality does not equate to approval of reality. In some instances, the client is led into another dialectical stance: accepting reality as it is in the moment, while (possibly) not approving and thus deciding to work in future to change things. So, the client might be hugely distressed that they have alienated a significant relationship with an over-the-top emotional reaction. DBT would take the stance that they should hold a point of tension with the two apparent irreconcilable facts: (1) They have responsibility for having created a bad situation relationally and must accept this reality (and themselves) and (2) they don’t have to approve of how they or the other person reacted; they can work in future to respond in ways which do not create ill will between themselves and another. They may be able to bear the distress of the moment better if they can make meaning of it: i.e., “Well, this event has shown me that things don’t work out well when I don’t modulate myself. I’m an ok person even if I lost my temper this time, but I can see now where I have room for improvement.” DBT skills training includes numerous crisis-survival techniques for distress tolerance (Linehan, 1993; Harvey & Rathbone, 2013).

It is beyond the scope of this article to discuss the specific exercises or skills practices that constitute each category, but for a more detailed examination, refer to Mental Health Academy courses focusing on dialectical behaviour therapy.

A rich set of techniques and strategies to improve the DBT client’s skills resides in the collection of skills taught in DBT group skills training, and many of the skills can be executed in one-on-one counselling situations. Moreover, they are not just appropriate for the population for which they were originally articulated: those with a borderline personality diagnosis. Rather, they address the broad-based deficits in interpersonal and intrapersonal skills, emotion regulation, distress tolerance, and staying in the present moment that plague most clients with mental health issues. We can do much to consolidate our clients’ life skills base by using this framework to optimise their effectiveness in everyday situations, thus improving their total quality of life.

Key takeaways

• Dialectical behaviour therapy has numerous components to help its original high-need clients: those with a diagnosis of borderline personality disorder.
• The component of group skills training has four aspects: mindfulness, interpersonal effectiveness skills, emotion regulation, and distress tolerance skills.
• Most of the skills do not need to be taught in a group and non-DBT practitioners will find them helpful to clients with a wide range of presenting issues, including deficits in interpersonal and intrapersonal skills, emotion regulation, distress tolerance, and staying in the present moment.

References

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• Goldberg, S.B., Riordan, K.M., Sun, S., Davidson, R.J.. The Empirical Status of Mindfulness-Based Interventions: A Systematic Review of 44 Meta-Analyses of Randomized Controlled Trials. Perspect Psychol Sci. 2022 Jan;17(1):108-130. doi: 10.1177/1745691620968771. Epub 2021 Feb 16. PMID: 33593124; PMCID: PMC8364929.
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• Linehan, M. (1993). Skills training manual for treating Borderline Personality Disorder. United States: Guilford Publications.
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• Miller, A.L., & Rathus, J.H. (2000). Dialectical behavior therapy: Adaptations and new applications. Cognitive & Behavioral Practice, 7, 420-425.
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