The Practice of Skill Training for Dialectical Behavior Therapy

Friday, 25 July 2014

Yasuko Koyano, PhD, RN, PHN
Health Care and Nursing, Juntendo University Graduate school, Chiba, Japan


The suicide rate in Japan is 24 per 100,000 population, the highest among the seven most developed countries, and Japan even ranks 9th even among the countries of the world as a whole. In 2010, the Ministry of Health, Labour and Welfare organized a “Suicide and depression management project team” as an approach to reducing the more than 30,000 suicides that occur in the country annually, and it has vigorously promoted measures to combat suicide. Cases in which patients take excessive amounts of psychotropic drugs prescribed by their physician for the treatment of depression, etc., have been pointed out, and the government has issued notices calling attention to the matter. Moreover, the existence of a situation in which multiple drugs are prescribed for psychiatric care in Japan in comparison with other countries has also been pointed out. Faced with this situation, there is a need for interventions designed to enhance psychosocial treatment with the goal of preventing suicide and depression without placing a disproportionate emphasis on drug therapy.

Dialectical behavior therapy is one of the psychosocial treatments that has been attracting attention in the US in recent years. This therapy was developed by M. Linehan of the University of Washington as a treatment program for borderline personality disorder (BPD), and clear evidence of the efficacy of this intervention has been presented. The therapy is applicable to a wide range of diseases, from eating disorders to anxiety disorders. Conventional cognitive-behavioral therapy focuses on “changes” in the patients’ cognition, therefore, the dropout rate from this therapy is considerable. Dialectical behavior therapy adopts Hegel’s dialectical philosophy and incorporates elements of “change” and “acceptance,” i.e., behavior therapy to solve problems and avoidance of value judgment focusing attention on the present moment, with mindfulness  as the core of the therapy. Mindfulness aims at establishing a state of mind not affected by emotions by observing the present distressed thinking and emotions, physical reactions and the feelings arising from such thinking, and acquiring the skills to accept unpleasant events. It is derived from the traditional Japanese teachings of Buddha and is, in particular, influenced by the Zen philosophy. Dialectical behavioral therapy consists of 4 modules, including 3 skills training modules, namely, “distress tolerance,” “emotion regulation” and “interpersonal effectiveness,” and mindfulness.”

The authors have been conducting an Emotional Literacy Program since 2009, held once a week for 90 minutes per session targeting patients of the day treatment center (day/night care) of an outpatient psychiatric unit. The program adopts an open group style with the maximum number of 10 participants per group, and any patient who wishes to participate can do so. At the beginning, the program was based on the Emotional Intelligence theory by Salovey and Mayer, but currently, it also introduces skill training with dialectic approach.

The structure of the basic sessions

Ninety-minute basic sessions, each consisting of a warm-up, lecture, exercise and sharing, are held weekly. Mindfulness, bridging from the previous session, checking homework assigned in the previous session, lecture and work on the day’s theme, the day’s homework and looking back are included in each session, referring to the structurization of cognitive therapy.

The first basic session provides an orientation in which the participants are explained about the course, to deepen their understanding of the dialectical approach. Basic sessions consist of 4 DBT skills training units, “distress tolerance skills,” “emotion regulation skills,” “interpersonal relationship skills” and “mindfulness.” Of these, mindfulness is added to the introduction of the other 3 skills training units each time, resulting in a structure made up of 3 modules.


The skills training influenced the consciousness of the patient and contributed to the control of feelings, correction of thoughts, and change of actions. As a result, the patient adopted a new role in society and a new outlook of life to lead a healthy and realistic life.

It is hoped that application of the program in psychiatric outpatient clinics and psychiatric day hospitals will serve as a useful intervention method aimed at altering feelings and as a system for enhancing self coping skills that will support living in the community and improve the quality of life of the parties concerned.