Time

Topic and Description

9:00-10:00am

History and Development of Dialectical Behavior Therapy

• Founder Dr. Marsha Linehan – clinical behavioral psychologist with personal history of severe emotional dysregulation and lengthy psychiatric hospitalization
• Addressing Chronic Suicidality and Borderline Personality Disorder in women
  • Chronic suicidal behavior and self-harm, frequently dropped out of standard CBT and reacted negatively to invalidation of traditional forms of therapy
  • Dr. Linehan began to develop a structured, behavioral treatment for clients with high risk behaviors and emotional dysregulation

Development of DBT as modified CBT

• CBT effective in behavior change but often invalidated emotional experiences of patients
• Patients needed more acceptance and validation before they could move to behavioral change
• Linehan integrated acceptance-based strategies inspired by Zen Buddhism with traditional behavioral change strategies
• DBT emerged with the balance between acceptance and change as a core dialectic

• Four treatment modes and skills training modules emerged in late 1980s.  Treatment modes include:
  • Individual therapy
  • Group skills training
  • Phone coaching
  • Therapist consultation team

Foundational Concepts of Dialectical Behavior Therapy

• Dialectics: the notion that two seemingly opposite things can be true at the same time.
  • Acceptance and Change: core dialectic within DBT - the ability to push for behavioral change while simultaneously accepting where someone is. “You’re doing the best you can AND you can do better.”
  • Validation and Self-Validation is a core acceptance strategy and a foundational skill that helps build connection, reduce emotional intensity and builds trust
  • 6 Levels of Validation: (1) Being Present;  (2) Accurate Reflection; (3) Mind Reading; (4) Understanding in Context; (5) Recognizing the Valid; and (6) Radical Genuineness
• Biosocial Theory: theory underpinning DBT that explains how emotional dysregulation develops and is maintained through an interaction between biological vulnerability (high emotional sensitivity and high emotional reactivity) and invalidating environment (family, individual, community, societal/cultural)

10:00am-10:15am

Practice validation strategies in role plays.

10:15-11:00am

Orientation and Structure of DBT

• Goals of DBT (problems to decreaseàbehaviors to increase)
  • Reduced Awareness and Focus/Confusion about Selfà Core Mindfulness Skills
  •  Emotional Dysregulation à Emotional Regulation Skills
  • Impulsivityà Distress Tolerance Skills
  • Interpersonal Problemsà Interpersonal Effectiveness
  • Teen-Family Challengesà Walking the Middle Path Skills
• DBT Assumptions: grounded in biosocial theory of emotional dysregulation; cognitive-behavioral theory and dialectical philosophy
• Overview of comprehensive/standard and considerations for offering modified versions of DBT:
  • Comprehensive includes individual therapy, skills group, phone coaching, and consultation team
  • Considerations for modified versions of DBT (e.g., adolescent DBT; skills-only focuses on DBT Skills groups and indicated for less acute populations)

11:00-12:00pm

DBT as an Evidence-Based Treatment

• First randomized controlled trial of DBT published by Linehan et al (1991) in Archives of General Psychiatry

• First empirically supported treatment for BPD and chronic suicidality
• Results showed DBT significantly reduced: suicidal behavior, psychiatric hospitalizations, therapy dropouts, anger and depression in individuals with BPD
• Opened the door for broader research and dissemination.

• General Research Overview of DBT
  • Most robust research supports: BPD, suicidality, self-harm
  • Strong emerging evidence: adolescents, substance use, eating disorders
  • Promising but developing: PTSD, mood/anxiety disorders, forensic populations
  • DBT is effective when emotion dysregulation is a core problem
• Clinical Application of DBT for Social Workers
  • Cooper and Parsons (2010). Dialectical Behaviour Therapy: A social worker intervention? Aetearoa New Zealand Social Work, 21(4) & 22(1), 83-93.
• Research Overview DBT for Adolescents and Children

1. Mehlum et al. (2014, J Am Acad Child Adolesc Psychiatry): DBT-A significantly reduced self-harm episodes, suicidal ideation, and depression; also had higher treatment retention.

2. Mehlum et al. (2016, J Child Psychol Psychiatry): Effects maintained over time (lower self-harm and suicidal thoughts).

3. McCauley et al. (2018, JAMA Psychiatry): DBT-A reduced suicide attempts, nonsuicidal self-injury (NSSI), and overall self-harm behaviors more effectively than supportive therapy.

4. Perepletchikova et al. (2011). Adapting Dialectical Behaviour Therapy for Children: Towards a New Research Agenda for Pediatric Suicidal and Non-Suicidal Self-Injurious Behaviors. Child Adolesc Ment Health., 16(2):116-121.

5. Perepletchikova F, et al (2017). Randomized Clinical Trial of Dialectical Behavior Therapy for Preadolescent Children With Disruptive Mood Dysregulation Disorder: Feasibility and Outcomes. J Am Acad Child Adolesc Psychiatry;56(10):832-840.

12:00-12:30pm

LUNCH BREAK

12:30-1:00pm

Break into 2-4 small groups and participants practice articulating the research of DBT for adolescents and/or children in a way that inspires participation/motivation of patients and families

1:00pm-2:00pm

Fundamentals of DBT

• Stages of Treatment for DBT
  • Stabilization- Achieving behavioral control (Stage 1)
  • Processing -- Experiencing Emotions Fully (Stage 2)
  • Building a Meaningful Life-- Building a Life Worth Living (Stage 3)
  • Flourishing-- Capacity for Joy and Freedom (Stage 4)
• Treatment Hierarchy
  • Behavioral Targets for Stage 1 include life threatening behaviors, therapy-interfering behaviors, quality of life interfering behaviors, and skills acquisition
• Diary Card:
  • Behavioral intervention that provides real-time self monitoring of emotions, urges, behaviors
  • Guides sessions to be focused and efficient: identify target behaviors, tracks frequency, intensity and contexts, and leads to application of chain analysis and skills coaching
  • Promotes skills generalization and enhances accountability
• Behavior Chain Analysis: a structured behavioral tool to examine the antecedents and consequences of behaviors. Goal is to identify vulnerabilities, triggers and links in the chain where new skills could be used instead of problematic behaviors.

2:00pm-2:30pm

Begin role play practice with a Diary Card. Give a case example to dyads. Have them take turns explaining and coaching a patient through the use of a diary card.

2:30pm-3:00pm

Consultation Team for DBT

• Its role in maintaining adherence, reducing therapist burnout, and modeling dialectical principles.
• Core functions of a DBT consultation team (e.g., providing support, increasing motivation, enhancing skills generalization, and maintaining treatment fidelity).
• Consultation team agreements and strategies to promote a dialectical balance between acceptance and change.

3:00-4:00pm

DBT Consultation Team Practice and Discussion

In small groups, discuss the elements of a consultation team for DBT therapists. In role plays, apply consultation team strategies to case examples involving high-risk clients, therapist invalidation, and treatment-interfering behaviors.

4:00-4:05pm

Review the homework assigned for tomorrow

Time

Topic and Description

8:45am-9:00am

Mindfulness Activity #1

9:00am-9:45am

Summary of Day One with any Follow-Up Questions. 

Homework Review #1: Describe the use of homework in DBT skills to increase generalizability. Leader will model homework review for a DBT multi-family skills group. Participants will engage by sharing homework assigned to them the night before.

9:45am-11:15am

DBT Skill Module - Core Mindfulness Module

What is Core Mindfulness in DBT: mindfulness is considered the foundation on which all other DBT skills (distress tolerance, emotion regulation, interpersonal effectiveness, walking the middle path) are built.

Without mindfulness, clients cannot notice urges, identify emotions, or choose skillful behaviors.

Theoretical Rationale for Mindfulness is based in Biosocial theory-- people with emotion dysregulation struggle with both emotional sensitivity and skill deficits.

Mindfulness targets these by teaching clients to:

Observe internal experiences (emotions, urges, body states) without being swept away.

Pause before reacting automatically.

Increase awareness of choices in the moments

DBT’s 3 States of Mind (Emotion-Wise-Reasonable)

Wise Mind is intuitive and integrates information from Emotion and Reasonable Minds to make decisions.

Mindfulness “What” Skills: observe, describe and participate

Mindfulness “How” Skills: don’t judge, stay focused and do what works

11:15am-12:00pm

In triads, practice teaching DBT states of mind, mindfulness “what” and/or mindfulness “how” skills

12pm-12:30pm

LUNCH BREAK

12:30pm-1:30pm

DBT Skills: Distress Tolerance Module

Distress Tolerance as a crisis intervention to help patients survive a crisis without making things worse. Strategies in this module will be reviewed including the following:

Distract with Wise Mind ACCEPTS (Activities, Contributing, Comparisons, Emotions, Pushing Away, Thoughts, Sensations)

Self-Soothe with Six Senses (Vision, Hearing, Smell, Taste, Touch, Movement)

Pros/Cons (Acting on Crisis Urges – pros/cons and Resisting Crisis Urges-pros/cons)

Improve the Moment (Imagery, Meaning, Prayer, Relaxation, One thing in the moment, Vacation, Encouragement)

Crisis Survival Kit (overview how to setup the kit with patients)

1:30pm-2:00pm

In groups of 4, practice explaining with examples of the distress tolerance skills (Participant 1=Distract with WISE MIND ACCEPTS, Participant 2=Self-Soothe with 6 Senses; Participant 3=Crisis Survival Kit; Participant 4=IMPROVE the moment)

2:00pm-2:30pm

DBT Skills: Distress Tolerance Module

Additional crisis intervention strategy often utilized in DBT is TIPP: Temperature, Intense Exercise, Paced Breathing and Progressive Muscle Relaxation (PMR)

Each strategy of TIPP is grounded in physiological science, particularly targeting the autonomic nervous system to rapidly reduce arousal. Dive Reflex as an example for “T” temperature skill.

Practice skills as they are taught – Temperature with measurement of heart rate (ice packs); Intense Exercise (pushups or burpees, optional); Paced Breathing; brief PMR experience

2:30pm-3:00pm

In small groups, apply a Distress Tolerance Skill to a clinical case scenario involving acute emotional crises, self-harm urges, or substance use. Share with larger group.

3:00pm-3:30pm

DBT Skills: Distress Tolerance Module

Radical Acceptance: fully acknowledging reality as it is, without judgment, resistance, or denial. Grounded in biosocial theory, dialectical philosophy, mindfulness, and behavioral science. Radical acceptance reduces unnecessary suffering, enhances emotional regulation, and creates a foundation for skillful action

Strategies to Support Radical Acceptance: Turning the Mind and Willingness/Willfullness

3:30-3:35pm

Homework Assigned for Tomorrow

Time

Topic and Description

8:45am-9:00am

Mindfulness Activity #2

9:00am-9:45am

Review of Learning from Day 2 and answer additional questions. Participants engage in small group homework review with 1-2 participants practicing as leaders of homework review.

9:45am-11:15am

DBT Skills: Emotion Regulation Module

• How we understand emotions in DBT (give us information, communicate to and influence others, and motivate/prepare us for action)
• Comprehensive explanation of A Model of Emotions including prompting event(s), vulnerability factors, thoughts, internal experiences, external experiences, action urges, actions, emotion and aftereffects.

11:15am-12:00pm

In small groups, participants will take turns role playing the Model of Emotions with practice patients

12:00-1:00pm

LUNCH BREAK

1:00-2:30pm

DBT Skills: Emotion Regulation Module

• ABC Please (accumulating, building, coping and treat physical illness, balance eating, avoid drugs, sleep, get exercise)
• Accumulating Positive Experiences (short term and long term) and Pleasant Activities – connected to reinforcement/behavioral activation theory
• Wise Mind Values and Priorities List: identify main values and connect these values to priorities
• Building Mastery (doing one thing each day to feel competent or control of life)
• Coping Ahead (rehearse a plan ahead of time with patients so they can be prepared when a stressor occurs)
• The Wave skill: observe/experience the emotion and engage in mindfulness of current emotions
• Check the Facts-- description of how to do this effectively
  • Describe problem
  • Sort actual facts of a situation from other interpretations
  • Identify goal in solving problem and brainstorm solutions

2:30pm-3:15pm

Opposite Action to Change Emotions:

Describe in depth the main emotions (fear, anger, sadness, shame, guilt, jealousy, and love) including common physical responses, common action urges.

3:15-4:00pm

Role Play in small groups of Opposite Action and Check the Facts. Small group discussion of main emotions and corresponding action urges/actions.

4:00-4:05pm

Homework assigned for tomorrow

Time

Topic and Description

8:45am-9:00am

Mindfulness Activity #3

9:00-9:30am

Review of Learning from Day 3 and respond to any additional questions. Participants engage in small group homework review with 1-2 participants practicing as leaders of homework review.

9:30am-10:30am

DBT Skills: Walking the Middle Path Module

Module is grounded in dialectical philosophy, biosocial theory, developmental psychology, and behavioral learning theory. The focus on this module is on teen-parent relationships and family interventions.

• Thinking Mistakes (all-or-nothing, catastrophizing, mind reading, overgeneralization, mental filter, disqualifying the positive, emotional reasoning, “should” statements, labeling, personalization)
• Typical Adolescent Behavior Psychoeducation for Parents
• Validation in Parent-Child Relationships (validation, self-validation and invalidation). How to validate while also holding boundaries with teens
• Dialectical Dilemmas (parent/child) including too loose/too strict; making too much of typical teen behavior/making light of problem behaviors; forcing independence/fostering dependence)
• Behavior Change strategies: reinforcement (positive/negative); shaping; extinction; punishment

10:30-11:00am

Clinical case examples of teen and parents presenting for family support provided to participants. Time provided for them to apply Walking the Middle Path main concepts, including validation, dialectical dilemmas and behavior change to the case.

11:00am-12:00pm

Overview of DBT for Children

Many differences, including intervention begins with parents and then moves to individual/family therapy with children.

Core Treatment Structure

• Parent Training & Involvement
  • Parents are taught the same skills alongside their children.
  • Special focus on validation skills and behavioral reinforcement.
  • Parents practice reinforcing skill use at home.
• Individual Therapy
  • Focuses on applying skills to real-life problems.
  • Uses behavioral chain analysis and problem-solving tailored to the child’s developmental level.
• Skills Training for Children
  • Adapted to be concrete, playful, and developmentally appropriate.
  • Uses visuals, stories, games, role-play.

Goals of DBT-C

• Reduce extreme emotional/behavioral outbursts.
• Increase use of adaptive coping skills.
• Improve emotion regulation, distress tolerance, and interpersonal skills.
• Strengthen parent–child relationship through validation and consistent reinforcement.
• Create a home environment that supports skills use rather than invalidation.

12:00-12:30pm

LUNCH BREAK

12:30pm-1:30pm

DBT Skills: Interpersonal Effectiveness Module

• Connecting relationships with values/goals
  • Keep and maintain healthy relationships (GIVE)
  • Get somebody to do what you want (DEARMAN)
  • Maintain your self-respect (FAST)
• Teach Skills with Examples
• GIVE skills: be Gentle, act Interested, Validate, and use an Easy manner
• DEARMAN skills: Describe, Express, Assert/Ask, Reinforce, Mindful, Appear Confident, and Negotiate
• FAST Skills: be Fair, no Apologies, Stick to values, and be Truthful

1:30pm-2:00pm

Practice role play with DEARMAN skill based on clinical case provided to participants

2:00pm-3:00pm

Implementing DBT Skills-only for Adolescents and Families in an outpatient clinical setting:

• Evidence on DBT skills only groups
• Program overview, structure of groups
• Exclusionary/inclusionary criteria for patients,
• Measurement: quality improvement and progress monitoring

3:00-3:30pm

Key Considerations for Working with Families

• Sessions grounded in DBT theory
• Balance acceptance and change
• Teach/model skills
• Focus on reinforcement
• Maintain structure/boundaries of session
• Normalize developmental struggles

3:30pm-4:00pm

Next Steps:

Participants will spend time discussing in small groups how they can integrate and apply DBT into current practice. Concerns or barriers encouraged to be discussed openly.

Question/Answer and Summary of Main Themes from training

4:00-4:15pm

Evaluations