DBT Training & Resources

Read this first: DBT-informed, not comprehensive DBT

Comprehensive DBT is a full treatment package with four parts running at once and a clinician team trained to fidelity (Linehan, 1993, 2015a). Orchard interns provide DBT-informed care: teaching and coaching DBT skills, using validation and chain analysis, inside ordinary individual therapy under supervision.

• Suicidality, self-harm, homicidality, and violent urges are never your independent determination. DBT was built for clients at high risk, so you will meet them. Any disclosure, urge, threat, or behavior goes to your supervisor the same day, and during the session if risk is acute.
• Do not teach any skill as a replacement behavior for self-harm without your supervisor’s direction. That includes TIPP and the other physiological skills.
• Recommend a comprehensive DBT program when a client needs one. Your supervisor makes that referral call with you.

What DBT is

Marsha Linehan developed DBT for chronically suicidal adults whose emotions overwhelmed every change-focused treatment they tried (Linehan, 1993). Three ideas organize it:

Target hierarchy

When several problems compete for session time, DBT works them in a fixed order (Linehan, 1993):

1. Life-threatening behaviorSuicidal and self-harm behavior, urges, and threats
2. Therapy-interfering behaviorMissed sessions, not doing practice, behavior of the therapist too
3. Quality-of-life behaviorSubstance use, housing, school, relationships, and other problems
4. Skills acquisitionBuilding the skills that replace the problem behavior

Comprehensive DBT: the four modes

Knowing the full model helps you explain the difference to clients and decide when to refer (Linehan, 2015a).

Adolescent DBT adds family members to skills training and a fifth module, Walking the Middle Path, on validation and behavior change within families (Rathus & Miller, 2015). For youth clients at Orchard, a parent attends with the child or adolescent.

The four skills modules

Skill names below follow Linehan (2015a, 2015b). Use the published handouts from the manual your client owns or that Orchard has licensed; do not copy them into Orchard materials.

Mindfulness

The foundation of every other module.

• Wise mind: where emotion mind and reasonable mind overlap
• “What” skills: observe, describe, participate
• “How” skills: nonjudgmentally, one-mindfully, effectively

Distress tolerance

Getting through a crisis without making it worse.

• STOP: stop, take a step back, observe, proceed mindfully
• TIPP: fast physiological skills (see the caution below)
• Pros and cons of acting on an urge
• ACCEPTS distraction and IMPROVE the moment
• Self-soothe with the five senses
• Radical acceptance and willingness

Emotion regulation

Changing emotions that can be changed, and lowering vulnerability.

• Naming emotions and their function
• Check the facts
• Opposite action when an emotion doesn’t fit the facts
• Problem solving when it does
• ABC PLEASE: accumulate positives, build mastery, cope ahead; treat physical illness, eat, avoid mood-altering substances, sleep, exercise

Interpersonal effectiveness

Getting needs met while keeping relationships and self-respect.

• DEAR MAN: asking for something or saying no
• GIVE: keeping the relationship
• FAST: keeping self-respect
• Deciding how intensely to ask

Core strategies you will use every session

Validation

Validation tells the client that their response makes sense. It is not agreement and not praise. Linehan describes six levels, from simple attention to radical genuineness (Linehan, 1997):

Chain analysis

A step-by-step reconstruction of one specific instance of a target behavior, used to find where a skill could have changed the outcome (Rizvi, 2019):

1. Define the behaviorOne specific episode, in observable terms
2. Prompting eventWhat started the chain
3. VulnerabilitiesSleep, illness, substances, stress that day
4. LinksEach thought, feeling, sensation, and action in order
5. ConsequencesWhat happened after, short and long term
6. SolutionsWhere a skill fits at each weak link; repair

Diary cards

A daily record of urges, behaviors, emotions, and skills used, reviewed at the start of each session to set the agenda by the target hierarchy. Use Orchard’s approved format; keep cards in the record, not on personal devices.

Commitment and dialectical strategies

• Devil’s advocate: argue against change so the client argues for it
• Foot in the door: start with a small commitment, then build
• Making lemonade out of lemons: find the usable part of a setback
• Irreverence balanced with warmth: an unexpected response can unstick a pattern; use it only after supervision has seen your relationship with the client

Using DBT skills at Orchard

Before you teach a skill

• Learn and practice it yourself first. You cannot coach what you have not done.
• Name it in the treatment plan, linked to a target. Your supervisor approves the plan.
• Check the client’s state: skills are learned in calm and used in distress. Teach in the first half of the session, not during a crisis.

By telehealth

• Confirm location, privacy, and a callback number at the start of every session, as always.
• Share handouts through the secure portal, not email.
• Have the client practice on camera, then report back on use between sessions.

With children and adolescents

• Include the parent, as Orchard’s model of care requires. Teach the parent the skill and the validation that supports it (Rathus & Miller, 2015).
• Simplify language and make it concrete and physical. Pair with the Play module for younger children.

Bring to supervision

• Any suicidal, self-harm, or homicidal content, and any violent urge, every time
• Diary cards and any chain analysis you completed
• Moments you felt pulled to rescue, argue, or withdraw. In DBT these are therapy-interfering behaviors of the therapist, and they belong in consultation.

What the evidence shows

• Adults with borderline personality disorder and suicidal behavior: comprehensive DBT roughly halved suicide attempts compared with treatment by community experts in a two-year randomized trial (Linehan et al., 2006). A Cochrane review found DBT among the better-supported therapies for BPD, with low-certainty evidence overall (Storebø et al., 2020).
• Adolescents at high risk for suicide: DBT reduced suicide attempts and self-harm compared with individual and group supportive therapy (McCauley et al., 2018).
• Skills on their own: skills training without the other modes shows promise for emotion dysregulation across diagnoses, but the evidence is thinner (Linehan et al., 2015; Valentine et al., 2015).

Practical meaning: when risk is high and chronic, comprehensive DBT is the evidence-based recommendation. DBT-informed skills are a reasonable part of treatment for many other clients.

Training and resources

Formal training

• Behavioral Tech, Linehan’s training organization: foundational and intensive DBT training
• DBT-Linehan Board of Certification: clinician and program certification
• The Linehan Institute: resources and finding comprehensive programs for referral

Books to own

• Linehan (2015a), DBT Skills Training Manual, and Linehan (2015b), the companion Handouts and Worksheets
• Rathus & Miller (2015), DBT Skills Manual for Adolescents
• Rizvi (2019), Chain Analysis in Dialectical Behavior Therapy

Orchard pages that pair with this one

• Mindfulness & Self-Regulation, the companion page
• Showing Up Whole: your own regulation in the room
• TeleMental Health: risk protocol and safety planning
• Crisis Support Resources

References