This series explores third wave cognitive behavioural coaching approaches. In part two, Jonathan Passmore examines the therapeutic approach (DBT) and how it can be adapted for use in coaching
Dialectical Behaviour Therapy (DBT) has been established as an intervention of choice for therapists working with specific types of presenting issues such as borderline personality disorder, and more recently has been applied to help clients manage eating disorders and violent behaviour.
However, unlike a number of other third wave cognitive approaches, such as Mindfulness, ACT and Compassion based coaching, DBT has not been applied to coaching. We believe DBT can be a useful addition to experienced coaches’ array of approaches, within a wider eclectic or integrated approach (Passmore & Leach, 2022).
DBT was developed by Marsha Linehan in early 1980s out of efforts to address the problems of clients with Borderline Personality Disorder (BPD) engaging in suicidal behaviour (Linehan, 1993). Linehan tested out her theory, which contributed to further refinements. DBT appeared to have a positive effect, leading to a reduction in suicidal and self-harm behaviour for clients, particularly those presenting with BPD (Linehan et al, 1991).
The result of this and subsequent studies have led to DBT becoming a widely used therapy with clients with BPD. While other BPD treatments have since been developed and tested, such as Schema-focused therapy, DBT remains a popular treatment by many clinicians as a result of its robust evidence base.
DBT places an emphasis on behaviour, rather than cognition. The DBT therapist sees their clients’ problems as behavioural, leading to the therapist targeting specific behaviours which need to change. This means that once the unhelpful behaviours are no longer observable, the disorder is considered to be resolved. In some senses, particularly when working with clinical populations, this philosophy provides hope that a stigmatising label, such as BPD, can be removed by the application of behavioural interventions.
The second strand is DBT’s focus on contemplative practices, encouraging clients to practise acceptance and living in the present moment, in the belief that these practices can reduce client distress resulting from rumination or anticipatory thoughts.
The third strand is using language and argument to explore the evidence. For example, when a client claims they want to die, the therapist disputes that dying is a good idea. In so doing, the client argues for why they wish to die – perhaps they are overwhelmed with anxiety. The therapist validates the emotion, but counter argues that dying is not a solution to their problem. The client experiences the therapist’s comments as indicating that the situation is understood. This helps to reduce their emotional distress, enabling them to start to explore the causes of their anxiety.
Such an approach is counter to approaches such as Motivational Interviewing, which would see wrestling with the client in this way counter-productive and instead favour a less confrontational approach.
Evidence
There have been a multiplicity of meta-studies of DBT (DeCou, Comtois & Landes, 2019; Cristea et al. 2017; Panos, Jackson & Hasan, 2013; Kliem, Kröger & Kosfelder, 2010; Ost, 2008), reviewing what is a substantial body of evidence on the efficacy of DBT. These have repeatedly found moderate effect sizes, making DBT comparable with many other recognised talking therapies, such as CBT.
As with most other third wave CBT practices, there is no research into the use of DBT in coaching, or in the workplace. As a result, at this stage, coaching practitioners must look to the research findings from therapy, but in doing so they should consider whether the findings might reasonably be repeated in coaching studies with non-clinical populations.
While many DBT studies have focused on suicide and self-harm, in the past decade DBT has been widely applied to anger management and aggression (Frazier & Vela, 2014). It is this body of evidence which arguably has the greatest relevance for coaches working with non-clinical populations, and which the author has experimented with in a number of client assignments.
While the sample size is too small to draw statistically significant outcomes, these individual case studies provide some evidence that in these specific cases, clients have found the DBC approach helpful and were able to apply the concepts to become more choiceful about their behaviours and reduce or completely overcome inappropriate aggressive behaviours in the workplace. We might call these approaches ‘DBT lite’, or Dialectical Behavioural Coaching (DBC), reflecting the less extreme nature of the behaviours and the less challenging nature of the clients.
Applying Dialectical Behavioural Coaching
DBC is not yet a recognised practice, but we believe it can grow to be widely used for specific types of presenting issues. We should point out that the author pioneered the application of mindfulness into coaching practice during 2002-7 (Passmore & Marianetti, 2007) and the application of Motivational Interviewing in coaching during the same period (Passmore & Whybrow, 2007), both third wave approaches, helping to translate them for coaching practitioners and incorporating them into coach training programmes at the University of East London and Henley Business School. Over the past two decades both have become widely used approaches.
Two tools drawn from DBC that may be usefully applied are RESISTT and ACCEPTS. These frameworks can be easily applied and prove popular with clients as they are practical and easy to remember.
RESISTT
The first tool to consider is RESISTT. RESISTT is a set of seven tools which can help clients manage overwhelming emotions (Van Dijk, 2020). Like many of these tools it works best by first explaining the framework to the client in the context of their behavioural trigger, and inviting them to consider which of the seven techniques best fits them and the context in which they are working. By using the word ‘experiment’ in the introduction of the framework, the expectation of a magical outcome is downplayed. Second, the client is given the freedom to ‘play’ with the intervention as they engage in an adult-adult relationship with the coach.
1. Reframing the Situation: Invite your client to step away from black-and-white thinking and adopt Grey Thinking or Reframing with a more evidenced based, logical and helpful thinking style
2. Engaging in a Distracting Activity: Remind your client that telling themself to: “Stop thinking about so-and-so” will just make them think more about that thing. Invite them to focus on something else: cooking a meal, preferably one they have not cooked before and thus requires careful planning; talk to a friend about their friend’s problem; watch a TV show or film; play an instrument or go for a run. The more sustained mental concentration the task requires the better this activity acts as a distraction.
3. Someone Else: Refocus your attention on somebody else. This is a great way to shift your attention to something other than the overwhelming emotions that you’re feeling or the situation that triggers your urges. For example, talk to a friend about a problem they have: this could be a DIY challenge or thoughts about changing their job.
4. Intense Sensations: Experiencing intense sensations that are not harmful to you can be a useful distraction. For example, take a cold shower, visit a sauna or steam room, or go for a wild swim in open water, a lake or mountain tarn.
5. Shut it Out: In a situation where the client starts feeling angry or anxious, a useful strategy is to leave the situation and go somewhere to relax or calm down. Encourage your client to visualise putting their problem in a box and putting the box aside for the time being.
6. Neutral Thoughts: Invite your client to focus on neutral thoughts by, for example, focusing on their breath or observing the environment around them and noticing the colours of the objects around them.
7. Take a Break: Taking a break will look different for everybody. Invite your client to pause and take some time off.
Through a collaborative conversation the client can be invited to reflect on the different approaches, and consider which might be most helpful for them in the different situations that trigger their behaviour.
By inviting the client to monitor their application of the different approaches and review their use at the next coaching session, greater awareness can be generated by the client about themselves, the content which triggers their behaviour and their preferred interventions. What is helpful is supporting the client with repeated use of the tools as rarely, if ever, does a single use lead to behavioural change. Instead the aim is to enhance awareness and strengthen the habituated nature of the new response.
ACCEPTS
ACCEPTS is the second framework with multiple dimensions that can be offered to coaching clients to consider and explore their preferred strategies. ACCEPTS aims to help clients by distracting them from focusing on the trigger event and the associated emotions, and encouraging them to focus on more positive aspects.
By focusing on more positive situations as a distraction, clients may elicit feelings of joy and happiness, and, in so doing, strengthen the pathways in their brain associated with the experience of pleasure, and reduce their experience, both in the short and longer term, of the negative emotions which cause them distress.
ACCEPTS stands for:
• Activities – engage in activities you enjoy
• Contribution – to others and the community
• Comparisons – to others less fortunate, or comparison to worse situations you have been in
• Emotions – engage in positive feelings and humour
• Push away – put the situation to the side for a while
• Thoughts – think about something else
• Sensations – experience a different intense feeling (eg, take a cold shower, eat a spicy food)
Using this approach, the coach would typically start by describing the ACCEPTS model, offer the seven steps as a menu from which the client can select. Like a buffet, the client can sample each and then make a decision as to which ones they wish to incorporate into their daily routine.
The coach may invite the client to describe and capture in a table, an item for each of the seven elements of the framework (see Table 1).
Having used the ACCEPTS table the coach can encourage the client to describe the option in more detail. The aim here is for the coach to create a visceral or emotional response associated with the item.
Finally, in the session, the coach would invite the client to plan a homework assignment in which they would experiment with the use of each of the items, in response to challenges that create the emotional presenting issue or trigger the behaviour they are trying to address.
Some clients experience out of control behaviours frequently, others less often, and thus the experiment may need to last a week, or two months, before the person has had a chance to experiment with all or several of the interventions. After each ‘experiment’, the coach and client can review the usefulness for the client and lessons learned at the next session. What typically emerges is that clients prefer two or three of the seven interventions and thus develop their own plans.
These are just two of a range of techniques drawn from DBC which can be used with clients to help manage over powering emotions leading to aggressive or unacceptable behaviours.
It is worth noting that DBT is a clinical approach and thus its application by coaches should be limited to those with psychological training or an understanding of psychological informed practice.
Conclusion
The evidence for DBT as an effective treatment for BPD has been demonstrated through multiple trials. The intervention shows that for some types of behaviour it is more effective in reducing self-harming than traditional forms of treatment for BPD. The approach has now also demonstrated efficacy in helping clients manage previously uncontrolled behaviours in the workplace and thus reducing or stopping uncontrolled aggressive and threatening behaviour.
- This series is based on content from Jonathan Passmore and Sarah Leach’s book: Third Wave Cognitive Behavioural Coaching (Pavillion, 2022).
ACCEPTS My actions
Activities
Contribution
Comparisons
Emotions
Push away
Thoughts
Sensations
Table 1. ACCEPTS client table
References
- I A Cristea, C Gentili, C D Cotet, D Palomba, C Barbui and P Cuijpers (2017). ‘Efficacy of psychotherapies for Borderline Personality Disorder: A systematic review and meta-analysis’, in JAMA Psychiatry, 74(4), 319-328. https://doi:10.1001/jamapsychiatry.2016.4287
- C R DeCou, A Comtois, and S J Landes (2019). ‘Dialectical Behavior Therapy Is effective for the treatment of suicidal behavior: A meta-analysis’, in Behavioural Therapy, 50(1), 60-72. https://doi.org/10.1016/j.beth.2018.03.009
- S N Frazier and J Vela (2014). ‘Dialectical behavior therapy for the treatment of anger and aggressive behavior: A review’, in Aggression and Violent Behavior, 19(2), 156-163. https://doi:10.1016/j.avb.2014.02.001
- S Kliem, C Kröger, and J Kosfelder (2010). ‘Dialectical behavior therapy for borderline personality disorder: A meta-analysis using mixed-effects modeling’, in Journal of Consulting and Clinical Psychology, 78(6), 936-951. https://doi.org/10.1037/a0021015
- M Linehan (1993). Cognitive Behavioural Treatment for Borderline Personality Disorder. Guilford Press: New York.
- M M Linehan, H E Armstrong, A Suarez, D Allmon, and H L Heard (1991). ‘Cognitive-behavioral treatment of chronically parasuicidal borderline patients’, in Arch Gen Psychiatry, 48(12), 1060-4. https://bit.ly/3h2x5wD
- L-G Ost (2008). ‘Efficacy of the third wave of behavioral therapies: A systematic review and meta-analysis’, in Behaviour Research and Therapy, 46(3), 296-321.https://doi.org/10.1016/j.brat.2007.12.005
- J Passmore and S Leach (2022). Third Wave Cognitive Behavioural Coaching. Shoreham-by-Sea, Sussex: Pavilion.
- J Passmore and O Marianetti (2007). ‘The role of mindfulness in coaching’, in The Coaching Psychologist, 3(3), 131-138.
- J Passmore and A Whybrow (2007). ‘Motivational interviewing: A specific approach for coaching psychologists’, in S Palmer and A Whybrow (eds), The Handbook of Coaching Psychology (pp160-173). London: Brunner-Routledge.
- P T Panos, J W Jackson, and O Hasan (2013). ‘Meta-analysis and systematic review assessing the efficacy of Dialectical Behavior Therapy (DBT)’, in Research on Social Work Practice, 24(2) 213-223. https://doi.org/10.1177/1049731513503047
- S Van Dijk (2013). DBT Made Simple. Oakland, CA: New Harbinger.