The Four Skill Modules
As mentioned, DBT is highly structured with regard to the content of sessions and assignments for clients. While treatment goals are individualized to meet each client's needs as appropriate for specific challenges and triggers, the therapeutic goals fall within four specific skill areas.
Mindfulness is regarded as a core skill in DBT. Mindfulness involves increasing awareness of self and context through observation, explanation, and involvement and the capacity to control the focus of one's attention on the current moment. Essentially, it is the capacity to pay attention, nonjudgmentally, to the present moment. Mindfulness in DBT incorporates the ability to focus on one thing in the moment and to identify effective responses to distress. This approach assists individuals in finding a synthesis between emotional experience and logical thought. It is through the ability to mindfully attend to one's current emotional state and identify the associated, often obstructive thoughts and the reactions and behaviors of self and others that solutions can be generated and applied. It is considered a basis for the other skills taught in DBT, because it assists individuals to embrace and tolerate the potent emotions they may feel when attempting to change their routine or exposing themselves to distressing situations. The concept of mindfulness and the meditative exercises used to teach it originate from customary Buddhist practice, although the skills taught in DBT do not involve any religious or metaphysical concepts.
Interpersonal response patterns taught in DBT skills training are comparable with those taught in many assertiveness or interpersonal problem-solving classes. They include efficient strategies for asking for what one needs, saying no, and coping with interpersonal conflict.
Individuals with BPD often have good interpersonal skills in a broad sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe appropriate responses when discussing another person encountering a problematic situation but may be completely incapable of conceptualizing or applying an appropriate response when analyzing a personal situation.
The interpersonal effectiveness module focuses on situations in which the purpose is to modify something or to stand firm against changes someone else is trying to generate,
thus resulting in goals such as learning to ask for what one needs or learning to say no. The skills taught are intended to maximize the likelihood that a person's goals in a specific situation will be met, while at the same time not damaging either the relationship or the person's self-respect.
Individuals with BPD and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. The DBT skills for emotion regulation include identifying and labeling emotions, identifying obstacles to changing emotions, reducing vulnerability, and increasing positive emotional events.
Many contemporary approaches to mental health counseling focus on altering distressing events and circumstances. They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been addressed by psychodynamic, psychoanalytic, Gestalt, or narrative therapies along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to tolerate pain skillfully.
Distress tolerance skills represent a natural development from mindfulness skills. They have to do with the ability to accept, in a nonjudgmental fashion, both oneself and the current situation. The objective is to become skilled in calmly recognizing negative situations and their impact rather than becoming overwhelmed or hiding from them. This allows individuals to make prudent decisions about whether and how to take action rather that falling into the intense, desperate, and often destructive emotional reactions that are part of BPD.
Skills for acceptance include radical acceptance, turning the mind toward acceptance, and learning to distinguish between reacting skillfully from a realistic understanding of the present situation (willingness) and trying to impose one's will regardless of reality (willfulness). Clients also learn four crisis survival skills to help deal with immediate emotional responses that may seem overwhelming: distracting oneself, self-soothing, improving the moment, and thinking of pros and cons.