In addition to this overall dialectical structure of therapy sessions, another tenet of DBT is the recognition that people are doing the best they can with the set of skills they currently possess. However, when people aren't doing very well, it implicitly suggests they must be lacking some important skills. Linehan determined what skills needed to be strengthened and then set about a method of correcting this. These skills are taught in DBT in four structured modules, in a group or classroom-like setting:
Module 1: Mindfulness Skills have to do with self-awareness. These skills draw upon Eastern and Western meditative practices. Mindfulness skills are considered the most essential skill set. This module forms the foundation for all the other skill modules. In the context of this module, mindfulness means living in the moment, and becoming aware of one's state of mind. This module teaches clients there are three states of mind: the reasonable mind, the emotional mind, and the wise mind.
The reasonable mind is the part of the mind that functions according to logic, rules, and rational analysis. The emotional mind is the part of the mind that provides meaning to things. It informs us about the importance of things, and allows for the complexity and intensity in relationship and other activities. Clients are taught that the reasoning mind and the emotional mind must be balanced so that they work together. When balanced, our actions are consistent with our goals. The wise mind permits and creates this balance between reason and emotion. The goal of this module is for clients to recognize when they operating from the wise mind; and, how to return to the wise mind when they are not. Clearly these skills are very important as it is believed that much of the difficulty that persons with Borderline Personality Disorder experience, result from an over-reliance on the emotional mind.
Module 2: Interpersonal Effectiveness Skills assist clients to become more skillful during interpersonal interactions, particularly those that may result in conflict. For instance, a client may need to learn how to discuss and negotiate a solution to a problem they are having with a neighbor. The client is taught a series of specific steps to follow. The step sequence enables them to function from the wise mind when dealing with interpersonal situations. First, they are asked to consider the objective of the interpersonal interaction: Is it to request a change, or to resist a change that someone else is requesting?
The goal of this module is to become interpersonally effective. This is demonstrated by the ability to honor one's values while avoiding unnecessary harm to a relationship. This entails the ability to balance a respect for others, with a respect for self. Specifically, students are taught how to balance self-respect with a desire for relationship. The skills include learning how to ask for things, saying no to requests, voicing an opinion, and standing up for oneself.
Module 3: Emotional Regulation Skills are skills that enable clients to better understand and cope with intense emotions. Clients receive some basic education about emotions:
1) the function of emotions;
2) the relationship between an interpretation of an event and the subsequent emotion;
3) the bodily responses to emotional states; and
4) the resulting urges or impulses to act out in response to emotion.
Clients learn specific techniques that enable them to better tolerate, reduce, or change the intensity of difficult emotions. This is achieved by learning to balance the emotional mind with the reasoning mind. Specifically, they must learn how to switch over from the emotional mind to the wise mind. The dramatic/emotional/erratic Cluster B personality disorders (Borderline, Narcissistic, Histrionic and Antisocial) are particularly prone to problems associated with emotional dys-regulation. Moreover, people with Borderline Personality Disorder are believed to use self-destructive behaviors (e.g., cutting, burning, and substance abuse) in an effort to regulate their emotional states.
Module 4: Distress Tolerance Skills refer to the ability to pass through crises, without making things worse. This resilience is achieved by acceptance and non-judgment of painful and distressing circumstances. Distress tolerance is founded upon the mindfulness skills. The goal is to neither ignore, nor wallow in, painful circumstances and events. Furthermore, students learn to operate from the wise mind during distress. This strengthens their ability to determine the best course of action rather than engaging in impulsive reactions to distressing events. Similar to the difficulty in regulating emotions, people with Borderline Personality Disorder tend to have a quite a bit of difficulty when crisis hits. Distress tolerance skills strengthen their ability to get through these tough times, without engaging in self-destructive behaviors or other impulsive acts.
DBT is a very structured treatment approach. In the pretreatment stage, clients are prepared for therapy and are oriented to the approach. The therapy relationship is highly collaborative as the client and therapist form a mutual commitment toward establishing the therapeutic goals. The goals are prioritized in terms of skills that must be learned in a hierarchical order. For instance, the reduction of suicidal behavior is prioritized over interpersonal effectiveness. The typical structure of DBT treatment consists of weekly individual therapy sessions, and a weekly skills training group. Each client is assigned an individual therapist who coordinates treatment among the other treatment providers who teach the skills modules. In addition, the individual therapist is available by telephone for immediate skills coaching. This enables clients to practice these skills in real-life settings.
DBT has recently been applied to a much broader clientele. It has been modified for treatment of adolescents, people with substance abuse, people with eating disorders, and for couple's therapy. DBT skills are even taught to law enforcement personnel as a preventive measure to help cope with stress and critical incidents at work. The effectiveness of DBT in treating Borderline Personality Disorder has been well documented in numerous research studies (Paris, 2008).
