Dialectical Behavior Therapy Skills Part 4: Distress Tolerance

Dialectical Behavior Therapy Skills Part 2: Interpersonal Effectiveness

In the last post, we began a discussion of DBT by providing an introduction to mindfulness, the core skills and the first module of the treatment. Today, I will shift my focus to the second module, interpersonal effectiveness. Before doing so, however, a brief description of what goes on in a skills training group seems worthwhile. Group sessions last two hours and typically include two co-leaders. During the first hour, the group members take turns briefly explaining a time when they successfully implemented a DBT skill in the prior week as well as a time when they were less successful in utilizing a DBT skill. Importantly, this is not treated as brief individual therapy sessions for each group member – that type of interaction is meant for the individual therapy component of DBT. Instead, this is a teaching tool, an opportunity for clients to practice speaking about emotional events in an objective, fact-based manner and for group members to problem-solve better ways for implementing certain skills into their lives. Group members organize their information during the week on “diary cards,” which list all of the DBT skills and provide space for the group member to indicate how often the skill was used and to list important notes. The second hour of the group session is devoted to teaching new skills. Co-leaders present material as though teaching a class, often utilizing Powerpoint presentations and providing handouts from the Skills Training Manual for Treating Borderline Personality Disorder.

When a skills training group first forms, they begin with the first module of treatment, mindfulness. After completing this module, the group transitions into interpersonal effectiveness. Upon completion of the interpersonal effectiveness module, the group reviews mindfulness skills before moving onto module three, emotion regulation. Mindfulness is then reviewed again prior to beginning the fourth module, distress tolerance. Generally speaking, a skills training group will complete two full cycles in a calendar year. Clients are told to expect to remain in treatment for two years which is quite long for an empirically supported treatment.

The interpersonal effective module is fairly broad and involves a variety of disparate skills, so this article will serve as an introduction to the topic best supplemented by further reading of the materials published by Marsha Linehan and her colleagues (see our references page or online store for recommended products for suggested readings). Borderline personality disorder (BPD), the disorder for which DBT was originally designed to treat, is characterized by stormy interpersonal relationships. Many studies have examined this point empirically and found evidence supportive of this diagnostic criteria. For example, Russell, Moskowitz, Zuroff, Sookman, and Paris (2007) found that individuals with BPD were more submissive and quarrelsome in interpersonal relationships than were individuals who did not meet the criteria for a mental illness. Additionally, Hill and colleagues (2008) found that, among DSM disorders (both Axis I and Axis II), BPD was the only disorder that specifically predicted dysfunctional romantic relationships and that individuals with BPD reported similar dysfunction in peer and work relationships. Selby, Braithwaite, Joiner, and Fincham (2008) found that perceived emotional invalidation – the tendency to have one’s emotional responses criticized and/or trivialized – partially explained the relationship between BPD and romantic relationship dysfunction. So, given all of this evidence, the need for the development of more effective interpersonal skills appears quite clear.

The skills that comprise the interpersonal effectiveness module are quite varied. One key point that the group members are taught is that, in any interpersonal interaction, there are a variety of priorities that must be managed and how those priorities are attended to will, in large part, dictate the degree to which an individual feels like she effectively managed the encounter. Specifically, Linehan points toward three types of effectiveness that must be considered in an interpersonal interaction:

  1. Objectives effectiveness
  2. Relationship effectiveness
  3. Self-respect effectiveness

Objectives effectiveness refers to prioritizing the accomplishment of clear, objective goals (e.g., obtaining a raise). Relationship effectiveness refers to the prioritizing of maintaining a conflict-free relationship (e.g., ensuring your boss still likes you). Self-respect effectiveness refers to prioritizing acting within your own principles so as to ensure that you feel comfortable with how you approached the situation (e.g., standing up for yourself, even if it costs you the raise and leaves your boss angry). In any situation, all three priorities need to be considered and, to some degree, rank-ordered. Whichever priority is of greater importance to the individual in that particular situation needs to be the primary focus, as regardless of the outcome of the situation, if that priority is addressed effectively, the individual is likely to feel reasonably satisfied with his role in the interaction.

One of the reasons this skill is particularly effective is that it forces individuals to consider their desired outcomes prior to taking action. Individuals with any of the disorders DBT has been shown to treat effectively (BPD, bulimia, and binge eating disorder) are typically characterized by a tendency to act impulsively when upset. As such, they often act without thinking about consequences due to an overpowering urge to reduce distress. As a result, conflicts become more likely and relationships become strained (or, alternatively, relationships are destructively fostered through undue submissions when the individual does not consider how being passive will impact his self-respect).

Identifying priorities is certainly a healthy tendency, but realizing this is important is not sufficient. Additionally, clients must learn how to go about enacting this interpersonal approach in their own lives. The interpersonal effectiveness module addresses this in a variety of ways, but I will focus on one particular set of skills – “DEAR MAN.” DEAR MAN is an acronym comprised of particular methods for successfully navigating a potentially difficult interpersonal interaction. The components of DEAR MAN are as follows:



Appear confident

To explain this skill, I will use a hypothetical example of Sarah, who approaches her roommate, Jessica about Jessica’s refusal to wash her own dishes. The first skill, describe asks Sarah to explain the situation to Jessica in concrete terms, without inserting her own interpretations or feelings (e.g., “Jessica, lately, I’ve noticed that you are piling your dishes in the sink rather than washing them.”).

Express asks Sarah to explain how this situation makes her feel. Notice, Sarah is asked to separate her feelings from the objective facts. Additionally, Sarah is asked to explain how she feels rather than assuming that Jessica will just know on her own (e.g., “This is frustrating to me because a clean house keeps my stress levels down.”).

The assert skill asks Sarah to clearly state her desired outcome (e.g., “What I would really like would be for us both to clean our dishes after we eat so they don’t pile up and food does not have time to harden and become difficult to remove.”). In this skill, it is important to be mindful of your tone of voice and to remain calm and composed.

DiscussionReinforce asks Sarah to explain why her goals will be beneficial (e.g., “If we do this, I will feel significantly less stressed at night and will be much less likely to snap at you and be irritable.”). In doing this, Sarah provides motivation for Jessica to consider her proposal.

The stay mindful skill reminds Sarah to keep her focus on her goal. Oftentimes, in potentially uncomfortable interactions, the other individual will either try to shift the focus of the conversation by bringing up other topics (e.g., “Well, you haven’t been getting me your share of the rent on time, so I don’t think you’re in a position to criticize me.”) or intimidate the initiator of the conversation by raising their voice, making threats, or calling names. If Sarah takes the bait, either fighting back by calling names or yelling or discussing the new topic, her goal becomes lost and unlikely to be accomplished. As such, she needs to not engage with Jessica when she tries such tactics. Instead, she is instructed to ignore inflammatory comments and to act like a “broken record” by consistently reiterating her point. In group, Sarah will learn to do this tactfully, taking care not to appear hostile in her response (e.g., “It sounds like there are some things you’d like for me to do differently too, but we’re discussing the dishes right now. Why don’t we resolve this first and then we can figure out a plan for the rent check.”).

The appear confident skill essentially preaches the mantra of “fake it until you make it.” The appearance of confidence can have a significant impact upon the way a person is seen and how he or she is responded to during a conversation. If Sarah is looking at the ground and stumbling over her words, Jessica will be less likely to take her seriously. If, on the other hand, Sarah maintains eye contact and appears composed, Jessica will be more likely to consider her points and respond with respect.

The final DEAR MAN skill, negotiate, teaches Sarah to give in order to get. In other words, DEAR MAN is a method for increasing the likelihood that a fair outcome will be attained in an interpersonal interaction. It is not a tool for making unsightly demands or ignoring the needs of others. As such, by using the negotiate skill, Sarah will acknowledge Jessica’s perspective and work with her towards a resolution, perhaps even asking Jessica what she thinks would be a good solution.

As you have likely noticed at this point, the interpersonal effectiveness module is heavily reliant upon the idea that interpersonal situations are more successful when an individual plans ahead and proactively considers the potential utility of each course of action. There are several more skills in this module as well as more detailed descriptions of the skills we covered in this article and we encourage you to read further as well as to comment here on DBT interpersonal effectiveness skills. In part three of this series, we will cover emotion regulation skills.

This post is by Mike Anestis who is a doctoral candidate in the clinical psychology department at Florida State University

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