Application of Fundamental Strategies in Behavioural Skills

Training

The overarching strategy in DBT is the emphasis on dialectics at every turn in

treatment.

Core DBT strategies are designed in pairs, representing acceptance on the one hand

and change on the other.

There are five major strategy categories:

 the overarching dialectical strategies

 core strategies (problem solving vs. validation)

 communication style strategies (irreverent vs. reciprocal)

 case management strategies (consultation-to-the-patient vs. environmental

intervention)

 integrative strategies.

The core strategies of problem solving and validation, together with the dialectical

strategies, form the essential components of DBT.

Communication strategies specify interpersonal and communication styles

compatible with the therapy.

Case management strategies specify how the therapist interacts with and responds

to the social network in which the client is enmeshed.

DBT is a modular treatment. The key characteristic of a modular treatment is that

the treatment provider can move the treatment strategies within various treatment

modules in and out of treatment as needed.

 Integrative strategies outline how to handle specific problem situations that may

come up during skills training, such as problems in the therapeutic relationship,

suicidal behaviors, therapy-destroying behaviors, and ancillary treatments.

Dialectical Strategies: Maintaining Therapeutic Balance

The dialectical focus in DBT occurs at two levels of therapeutic behavior. At the first

level, a skills trainer must be alert to the dialectical balance occurring within the

treatment environment.

The second level of dialectical focus is on teaching and modeling dialectical thinking

as a replacement for dichotomous, either–or, black-and-white thinking.

Specific dialectical strategies

The most common dialectical strategies in DBT are storytelling and metaphors.

At the very start of skills training, the opportunity arises to enter the paradox of how

it can be that everyone is doing the best they can and simultaneously everyone

needs to do better. Entering the paradox here requires the trainers to refrain from

providing rational explanations; in order to achieve understanding and to move

toward synthesis of the polarities, each person needs to resolve the dilemma for

themself.

Playing the devil’s advocate is another key strategy. A trainer presents a

propositional statement that is an extreme version of one of a client’s own

dysfunctional beliefs, and then plays the role of devil’s advocate to counter the

client’s attempts to disprove the extreme statement or rule.

It is an important strategy for helping clients let go of ineffective myths about

emotions and about using interpersonal skills.

 Dialectics are critically important in the two most important characteristics of skills

training: assessing use of skills and teaching new skills.

Assessing dialectically involves openness to being incorrect in one’s analysis and

understanding of clients’ difficulties with skills. It is always asking the question “What

is being left out here?”

It is extremely important for therapists not to get into a battle of trying to prove that

the skills being taught are the only right way to handle every situation, or even any

particular situation. Although the skills may be very effective for some purposes,

they are not more “right” than other approaches.

Typical dialectical tensions

Feelings and beliefs vs wise mind

The strategy of “wise mind” is the first core mindfulness skill taught and should then

be encouraged throughout skills training.

When a client makes a statement representing an emotional or feeling state as if the

feeling state provides information about the empirical reality, it is effective at times

simply to question the client: “I’m not interested right now in what you believe or

think. I am interested in what you know to be true in your wise mind. What do you

know to be true? What does wise mind say is true?”

The dialectical tension is between what the client believes in “emotion mind” and

what they think to be true (“reasonable mind”); the synthesis is what they know to

be true in wise mind.

 Willingness vs willfulness

The essential tension is between responding to a situation in terms of what the

situation needs (willingness) and responding in a way that resists what a situation

needs or responding in terms of one’s own needs rather than those of the situation

(willfulness).

Thus, willfulness encompasses both trying to “fix” the situation and sitting passively

on one’s hands, refusing to respond at all.

The synthesis of willfulness on each side is willingness. It is critically important to

remember that no matter how aversive a client’s behavior may be, willfulness

cannot be fought with willfulness. Thus, it is critical that therapists respond to

willfulness with willingness.

Core Strategies: Validation and Problem Solving

Validation

The validation strategies (representing core acceptance) are essential to DBT.

Problem solving must be intertwined with validation.

Validation strategies involve a nonjudgmental attitude and a continual search for the

essential validity of each client’s responses.

The first general task in validating during skills training is to help clients observe and

accurately describe their own emotions, thoughts, and overt behavior patterns.

Second, skills trainers communicate empathy with clients’ emotional tone, indicate

understanding of (though not necessarily agreement with) their beliefs and

expectancies, and/or make clear observations of their behavioral action patterns.

 Third, and most importantly, the trainers communicate that the clients’ emotional

responses, beliefs/expectancies, and overt behaviors are understandable and make

sense in the context of their lives and the current moment.

The essence of validation is this: The skills trainers communicate to the clients that

their responses make sense and are understandable within their current life context

or situation.

The trainers actively accept clients and communicate this acceptance to clients.

Clients’ responses are taken seriously and are not discounted or trivialized.

Validation strategies require the skills trainers to search for, recognize, and reflect to

the clients and/or the group as a whole the validity inherent in their responses to

events.

Two things are important to note here. First, validation means the acknowledgment

of that which is valid. It does not mean “making” valid. Nor does it mean validating

that which is invalid. Second, “valid” and “scientific” are not synonyms.

Validation can be considered at any one of six levels. Each level is correspondingly

more complete than the previous one, and each level depends on the previous

levels. Taken as a whole they are definitional of DBT and are required in every

interaction with the client.

Level 1

At Level 1 of validation, the skills trainers listen to and observe what clients are

saying, feeling, and doing.

They also make corresponding active efforts to understand what is being said and

observed.
 Validation at Level 1 communicates that the client per se, as well as the client’s

presence, words, and responses in the session, have “such force as to compel serious

attention and [usually] acceptance.”

Level 2

At Level 2 of validation, the skills trainers accurately reflect back to the clients the

clients’ own feelings, thoughts, assumptions, and behaviors.

The skills trainers convey an understanding of the client by hearing what the clients

have said, and seeing what the clients do and how they respond.

Validation at Level 2 sanctions, empowers, or authenticates that each individual is

who he or she actually is.

At Level 2, the skills trainers are always checking to be sure that their reflections are

accurate, and are always willing to let go of their previous understanding in favor of

a new understanding.

Level 3

At Level 3 of validation, the skills trainers articulate the unverbalized.

The skills trainers communicate understanding of aspects of the clients’ experience

and response to events that have not been communicated directly by the clients.

The trainers “mind-read” the reasons for the clients’ behavior and figure out how

the clients feel and what they are wishing for, thinking, or doing, just by knowing

what has happened to the clients.

Level 3 validation is most important in the review of homework and in responding to

clients’ difficulties in learning, accepting, or practicing new skills.

Level 4

At Level 4, behavior is validated in terms of its causes. Validation here is based on

the notion that all behavior is caused by events occurring in time; thus, in principle, it

is understandable.

The skills trainers validate (this validation is not to be confused with “approval” or

“excusing”) the clients’ behavior by showing that it is caused by past events.

Even though information may not be available to determine all the relevant causes,

the clients’ feelings, thoughts, and actions make perfect sense in the context of the

clients’ current experiences, physiology, and lives to date.

Level 5

At Level 5, skills trainers validate in terms of present context or normative

functioning.

Skills trainers communicate that behavior is justifiable, reasonable, well grounded,

meaningful, and/or efficacious in terms of current events, normative biological

functioning, and/or clients’ ultimate life goals.

The skills trainers find the relevant facts in the current environment that support

clients’ behaviors. The clients’ dysfunction does not blind the skills trainers to those

aspects of response patterns that may be either reasonable or appropriate to the

context.

Thus, the skills trainers search the clients’ responses for their inherent

reasonableness (as well as commenting on the inherent dysfunction of various

aspects of these responses, if necessary).

Level 6

Level 6 of validation requires radical genuineness on the part of the skills trainers.

The task is to recognize each person as they are, seeing and responding to the

strengths and capacities of the client, while keeping a firm empathic understanding

of their actual difficulties and incapacities.

The skills trainers believe in each client and their capacity to change and move

toward ultimate life goals, just as they may believe in a friend or family member.

Validation at the highest level is the validation of the individual “as is.” The skills

trainers see more than the role—more than a “client” or a “disorder.”

Whereas Levels 1–5 represent sequential steps in validation of a kind, Level 6

represents change in both level and kind.

Cheerleading strategies

Cheerleading strategies constitute a further form of validation and are the principal

strategies for combating active passivity and tendencies toward hopelessness in

many clients with serious emotion dysregulation.

In cheerleading, skills trainers communicate the belief that clients are doing their

best and validate clients’ ability to eventually overcome their difficulties.

In addition, skills trainers express a belief in the therapy relationship, offer

reassurance, and highlight any evidence of improvement.

Although active cheerleading should be reduced as clients learn to trust and to

validate themselves, cheerleading strategies always remain an essential ingredient of

a strong therapeutic alliance.

 Functional ideation

It is a form of nonverbal or behavioral validation that, at times, may be more

effective than verbal validation.

For example, if a skills trainer drops a 50-pound block on the client’s foot, it would

be considered invalidating if the trainer’s response is to do nothing except say,

“Wow, I can see that really hurts! You must be in a lot of pain.” Functional validation

would entail the trainer’s removing the block from the client’s foot.

Problem solving

Problem solving strategies are each aimed at change and are basic components of all

major CBT approaches.

Contingency management procedures

Every response within an interpersonal interaction is potentially a reinforcement, a

punishment, or a withholding or removal of reinforcement.

Contingency management is the provision of consequences for specific behaviors,

aimed at increasing or maintaining behaviors that are wanted and decreasing

behaviors that are not wanted.

The basic idea in contingency management is that a client’s adaptive functional

behavior results in reinforcement, whereas negative maladaptive behavior results in

either aversive consequences or no discernible consequences that could reinforce

the behavior.

It is important not to assume that any particular response to a client’s behavior is a

positive reinforcer without checking.

It is also important to note that praise of skills use may or may not reinforce clients’

skillful behaviors. For example, if an individual’s history involves many instances in

which praise and acknowledgment of skill and strength have led to an absence of

further help and/or higher expectations, praise may be aversive instead of

rewarding.

It is not a good idea, however, to stop praising skillful behaviors altogether, for two

reasons. First, a client can interpret the absence of praise as never being able to do

anything right—in other words, as implied criticism. Second, praise in most settings

is meant as a reinforcer, and it is important for praise to become a reinforcer for

clients.

The best strategy is not to go overboard with excessive praise, but to give clear

feedback about skillful behavior, and when necessary to follow this immediately with

recognition that this does not mean the client can solve all of his or her problems or

has no more problems to be solved.

It is also important to remember to balance praising effective use of skills with

praising effort even when it is not effective. Praise of effort is particularly important

when new behaviors are being shaped.

As far as possible, skills trainers should try to provide natural reinforcers for clients’

adaptive behavior. “Natural reinforcers” are consequences that clients can expect in

everyday life.

As begin to apply the skills being taught, skills trainers must be careful to respond in

a manner that will reinforce such improvement. Although shaping principles require

the trainers eventually to “up the ante,” so to speak, by requiring even more skillful

behavior, these increases in demands must be kept gradual.

In “shaping,” gradual approximations to the target behavior are reinforced. Shaping

requires a skills trainer to break the desired behavior down into small steps and to

reinforce each of these steps sequentially.

Without shaping, both skills trainers and clients would become so frustrated and

distressed that skills training could not proceed. Thus, it is crucial that skills trainers

continually model shaping principles.

As important as reinforcement is the withholding of reinforcement for behaviors

targeted for extinction.

The problematic behaviors of emotionally dysregulated clients are often quite

effective in obtaining reinforcing outcomes or in stopping painful events.

Contingency management at times requires the use of aversive consequences similar

to “setting limits” (punishment) in other treatment modalities, as well as the

systematic and tenacious withdrawal of usual reinforcers (extinction).

Three guidelines are important in using aversive consequences.

 Punishment should “fit the crime,” and a client should have some way of

terminating its application.

 It is crucial that skills trainers use punishment with great care, in low doses,

and very briefly, and that a positive interpersonal atmosphere be restored

following any client improvement.

 Punishment should be just strong enough to work.

Generally, aversive procedures should be used when a client is avoiding difficult

activities such as coming to skills training sessions, doing homework, practicing in

sessions, or engaging in active problem solving.

 In these cases, it is essential to intervene immediately and push clients, instead of

ignoring them and allowing the avoidance to continue. In other words, the avoidance

response must be short-circuited.

The idea is to make the immediate consequences of avoiding more aversive than

those of not avoiding.

Positive maladaptive behaviors should be put on an extinction schedule. A skills

trainer ignores the client’s maladaptive behaviors and continues to interact with the

client as if he or she is not producing such behaviors.

Or, if the behaviors cannot be ignored, the trainer can make a brief comment

suggesting that the client cope by using some of the skills being taught in the current

(or a past) skills module.

It is very important to remember to soothe clients whose behavior is on an

extinction schedule and those who are receiving aversive consequences. In each

case, the behavior is what is being punished, not the person.

Exposure-based procedures

Structured exposure procedures, (e.g., prolonged exposure for PTSD), are not used in

DBT skills training.

DBT skills training, however, can be effectively combined with exposure-based

protocols, and many principles of exposure are woven throughout DBT skills.

Cognitive restructuring

There are a number of structured exercises throughout the skills training program

for helping clients check the facts of a situation and modify dysfunctional

assumptions and beliefs.

 The mindfulness skills of describing and being nonjudgmental focus intensely on

teaching clients how to describe what is observed, and how to tell the difference

among observing an event in the environment, a thought about the event, and an

emotion about the event.

However, formal cognitive restructuring plays a much smaller role in DBT than in

other forms of CBT, and cognitive techniques play only a small role in DBT treatment

of disordered emotion regulation in particular.

Stylistic Strategies

DBT balances two quite different styles of communication that refer to how the

therapist executes other treatment strategies.

The first, “reciprocal communication,” is similar to the communication style

advocated in client-centered therapy. The second, “irreverent communication,” is

quite similar to the style advocated by Carl Whitaker in his writings on strategic

therapy.

Reciprocal communication strategies are designed to reduce a perceived power

differential by making the therapist more vulnerable to the client. In addition, they

serve as a model for appropriate but equal interactions within an important

interpersonal relationship.

Irreverent communication is usually riskier than reciprocity; however, it can facilitate

problem solving or produce a breakthrough after long periods when progress has

seemed thwarted.

To be used effectively, irreverent communication must balance reciprocal

communication, and the two must be woven into a single stylistic fabric.
Reciprocal communication strategies

Responsiveness, self-disclosure, warm engagement, and genuineness are the basic

guidelines of reciprocal communication.

Self-involving self-disclosure in individual therapy consists of a therapist’s

immediate, personal reactions to a client and their behavior.

Reciprocal communication in the context of skills training requires that trainers make

themselves vulnerable to their clients and express this vulnerability in a manner that

can be heard and understood by the clients.

Therapists’ expressions of vulnerability in sessions not only address the power

imbalance that all clients experience, but also can serve as important modeling

events.

Such expressions can teach clients how to draw the line between privacy and

sharing, how to experience vulnerable states without shame, and how to cope with

their own limitations.

One of the easiest ways to use reciprocal communication in skills training is for the

skills trainers to share their own experiences in using the skills being taught.

The use of self-disclosure is an important part of DBT. In skills training, modeling uses

of skills and ways of coping with adversity is the most frequent form of self-

disclosure.

The primary rule is that disclosure must be in the interest of the clients, not the

interest of the skills trainers.

Irreverent communication strategies

Irreverent communication is used to push a client “off balance,” get the client’s

attention, present an alternative viewpoint, or shift the client’s affective response.

It is a highly useful strategy when the client is immovable, or when therapist and

client are “stuck.”

An important value of irreverence is that unexpected information is more deeply

processed cognitively than expected information is. For irreverence to be effective, it

must both be genuine (vs. sarcastic or judgmental) and come from a place of

compassion and warmth toward the client.

When using irreverence, a therapist highlights some unintended aspect of the

client’s communication or “reframes” it in an unorthodox manner.

Irreverent communication has a matter-of-fact, almost deadpan style that is in sharp

contrast to the warm responsiveness of reciprocal communication. Humor, a certain

naiveté, and guilelessness are also characteristic of the style.