Three DBT Strategies to Be Sure to Apply

The highlight (didactic) of the 2014 ISITDBT (International Society for the Improvement and Teaching of Dialectical Behavior Therapy) gathering for me was Melanie Harned and Kate Korslund's presentation on "Improving Competence in DBT: Avoiding Common Adherence Pitfalls." The bullet points below are from their handout. They outlined a system of coding videos for adherence. Each then shared clips from a less than perfectly adherent session...and bravely invited a group coding, that is 400+ of us in the room at the time, to score them for adherence. How validating to see examples of mistakes and omissions!

Harned and Korslund presented their findings from nearly 1500 sessions that have been coded for adherence over the last 10 years. The strategies and procedures of DBT have been analyzed as 12 subscale scores (*see below). The three subscales most commonly coded as insufficient were: dialectical strategies, exposure, and problem solving. It was suggested that more attention be placed on modeling a dialectical worldview by generating balanced solutions and striving for dialectical synthesis. This could be largely remedied with more "Both-And" language.

• Adopt and model a dialectical worldview
• Infuse session language with dialectical language. Add "Both-And"
• Strive to balance nurturance and acceptance with push for change
• Generate both acceptance-based and change-based skills and solutions

How can we show that we believe and live a dialectical view, including more Both-And and less Either-Or? What is left out? How can we acknowledge and accept the polarities at play? How can we hold both polarities (in our open hands)?

We were encouraged to look for opportunities to use formal and informal exposure and to implement each step (Kelly Koerner's PracticeGround Learning Community provides effective training on this).

• Use it! Look for and create opportunities
• Highlight and block efforts to avoid emotions in session
• Redirect clients back to the cue for a sufficient length of time (while blocking avoidance)
• Obtain ratings of distress before and after

Even if we are not highly trained in formal exposure, how can we look to use informal exposure? Can we be on the lookout for when an emotion is avoided, such as when a joke is cracked that serves to avoid? What helps us to coach our client back to experiencing the emotion? Do we notice avoiding for a sufficient amount of time? Do we continue our conversation with the emotion? Have we checked the SUDs level before and after?

Problem-solving could be improved by emphasizing agreement and commitment to implement new behaviors and to troubleshoot.

• Generate solutions that are reflective of the major problems
• Ensure that solution generation translates to behaviors that will be tried
• Be specific and clear on the new plan
• Seek agreement to implement new behavior
• Troubleshoot

Do we actually have an agreement? Let's troubleshoot this plan-what might get in the way? Do we have sufficient detail? Are we clear on the consequences in the chain? Have we clarified the contingencies relevant to the new plan?

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* The 12 subscales: Reciprocal, Validation, Contingency Management, Structural, Cognitive, Irreverent, Assessment, Protocols, Problem Solving, Dialectical, Exposure