If you have come across this post, you are likely aware that dialectical behavior therapy (DBT) is an evidence-based approach to support individuals who struggle with emotion dysregulation. Practitioners who incorporate DBT into their clinical work say that DBT is magical for some clients because it can propel these individuals into taking steps to lead a life worth living. Unfortunately, that magic seems to elude other clients, many of whom would greatly benefit from emotion regulation and interpersonal effectiveness skills.
If you have facilitated a group on DBT skills, you may find the following scenario quite familiar:
Every client in the group holds a paper copy of Distress Tolerance Handout 11 from the infamous DBT Skills Training Handouts and Worksheets manual. Each group member is taking turns reading about radical acceptance. As you begin to expand on why it is important to accept reality, you notice clients nodding off, one by one. To engage the group, you ask, “Is anyone willing to share a reality they are currently fighting?” Nobody answers. You provide a personal example about how you did not want to radically accept that you stained your shirt this morning when you spilled your freshly made blueberry smoothie. You ask the group what this example brings up for them. Silence. You then ask if anyone has questions. A client speaks up: “Can I use the bathroom?”
If this scenario resonates, know that you are not alone. Many mental health professionals report that they struggle to keep their clients engaged when they are providing psychoeducation on DBT skills. What is this phenomenon?
Thankfully, preliminary research helps us understand why some clients “check out” during DBT skills training groups. In this post, I will share some of the reasons why Marsha Linehan's magical treatment is not always accessible to clients.
If you are familiar with DBT, feel free to skip this section. For those of you who are new to the modality, here is a quick overview.
DBT combines behavioral sciences and Zen practices, proposing that pathology is rooted in an inability to regulate emotion. American psychologist Marsha Linehan (1993) developed DBT in the early 1990s as a treatment for women diagnosed with borderline personality disorder (BPD).
Clients who participate in adherent DBT treatment attend weekly individual therapy sessions and psycho-educational groups. This format provides space for processing and supports clients in learning and implementing a wealth of tangible skills that can replace harmful behaviors. Despite the sophistication of DBT treatment, the model proposes relatively straightforward concepts that support individuals who have difficulty regulating emotions.
A unique component of the adherent model of treatment is DBT skills training, the psychoeducation groups that clients attend in addition to individual therapy sessions. DBT skills training is divided into four modules designed to increase a client’s repertoire of skills:
Adherent DBT skills training groups last 48 weeks and cover all four modules; however, research has demonstrated that modified DBT skills training groups can also be effective (Miga, 2018).
Here are some common responses to DBT Skills Training.
“DBT makes me uncomfortable.”
While some clients fall in love with DBT (hello to all of the DBT-heads out there), others have difficulty tolerating DBT skills training. Researchers who studied why clients were dropping out of DBT treatment found that these clients were experiencing unwanted emotions, disengaging from the content, or struggling to understand the material (Barnicot et al., 2015; Cancian et al., 2019; Clark, 2017; Little et al., 2017). The most common reason for quitting treatment was difficulty tolerating the unpleasant experiences in the group process. This makes sense—the clients may not have had a chance to learn the skills required to tolerate uncomfortable internal experiences.
To put this evidence more simply, some clients stop doing DBT because they are uncomfortable.
For example, seven studies reviewed by Little and colleagues (2017) found that participation in DBT skills training caused group members to feel anxious and insecure. Cancian and colleagues (2019) examined an adapted DBT skills training group intervention for obese individuals. They observed that participants frequently compared themselves with others and felt pressure to provide feedback to their peers. A qualitative interview study of barriers to DBT skills training for clients diagnosed with BPD found that clients felt insecure during the group because they feared peer judgment (Barnicot et al., 2015).
Some clients reported that they left DBT groups because “authoritarian and strict” facilitators caused them to experience a high level of anxiety (Barnicot et al., 2015). Group members reported feeling intense emotional discomfort and an inability to regulate their emotions. Again, this makes sense. These clients may not have internalized or generalized distress tolerance skills; as a result, they could not implement them when activated.
“DBT is boring.”
Although I am passionate about DBT, I can understand why others may find the modality to be a bit boring. Clever acronyms aren’t always enough to make learning fun (though I feel like they add a little pizazz to the process)!
Research has indicated that difficulty holding clients’ attention in DBT skills training is a consistent obstacle across populations (Barnicot et al., 2015; Clark, 2017; Linehan, 1993). Clark (2017), who provides art-informed DBT treatment to clients diagnosed with eating disorders, reported that, even when working with experienced and dynamic facilitators, many patients complained of boredom in her skills training groups.
In my work running applied DBT skills training groups with adults, I have had similar experiences with many of my clients. Group members tell me they feel “tired” and the skills I am teaching them are “boring.” I’ll admit that I have had a client or two nod off in the middle of the group. When a client started to snore during my 11 a.m. group a few years ago, I knew I had to find a way to keep participants engaged.
“I don’t get DBT.”
There are many DBT skills, and some concepts can be challenging to grasp. The dialectic, for example, can really throw folks for a loop.
Studies show that many clients report having difficulty comprehending the information presented during sessions. In their systematic review of client responses to DBT treatment, Little and colleagues (2017) found that some participants felt that the language used in treatment was intimidating and difficult to understand. Participants frequently felt confused by the “jargon” facilitators use. Barnicot and colleagues’ (2015) research suggested that participants had difficulty understanding the concepts because the material was presented too quickly. The results of Cancian and colleagues’ (2019) research provided additional evidence that some participants experienced barriers to learning. Clients reported challenges learning, remembering, and applying skills outside the session.
All and all then, the research indicates that clients drop out of DBT skills training due to difficulty tolerating and regulating emotions, staying engaged in the content, and understanding the material. If you have facilitated applied or adherent DBT skills training groups, you probably have some lived experience with these barriers.
Here is the good news: preliminary research suggests that there are strategies facilitators can use to help a wider range of clients access treatment. For example, creating a supportive environment, personalizing skills, and utilizing creative strategies can decrease dropout rates and increase skill learning.
If you are tired of feeling stuck and want some support running your DBT groups ASAP, check out the Action-Based DBT program manual. This ebook provides creative arts strategies to teach a wide range of DBT skills.
References
Barnicot, K., Couldrey, L., Sandhu, S., & Priebe, S. (2015). Overcoming Barriers to Skills Training in Borderline Personality Disorder: A Qualitative Interview Study. PLOS One, 10(10).
Cancian, A. C. M., de Souza, L. S., & da Silva Oliveira, M. (2019). Qualitative analysis of a Dialectical Behavior Therapy adapted Skills Training group for women with obesity. Contextos Clínicos, 12(3), 707.
Clark, S. M. (2017). DBT-Informed Art Therapy: Mindfulness, Cognitive Behavior Therapy, and the Creative Process. Jessica Kingsley Publishers.
Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press.
Little, H., Tickle, A. C. & das Nair, R. (2017). Process and impact of dialectical behaviour therapy: A systematic review of perceptions of clients with a diagnosis of borderline personality disorder. Psychology and Psychotherapy, 91(3), 278–301.
Miga, E. M., Neacsiu, A. D., Lungu, A., Heard, H. L., & Dimeff, L. A. (2018). Dialectical Behaviour Therapy from 1991 to 2015. The Oxford Handbook of Dialectical Behaviour Therapy, 415.
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