How does one master DBT?

There are 5 primary modes of learning within the two categories of extrinsic (conscious) and intrinsic (mostly unconscious).  Explicit memory is mostly a conscious process and is composed of autobiographical and semantic memories.  Autobiographical memory is for events we experience, such as a memory of the amusement park we went to as a child. Semantic memory is for learning concepts and facts. Much of our awareness of learning comes from our conscious effort to learn information through explicit processes. This is why typical schools require effort to sit still, stay on task and absorb information through more passive processes of seeing and listening. These processes evolved more recently and value knowing large amounts of information over understanding something to a deeper level.

Humans have had a long history of learning by experience through implicit memory. Implicit memory is acquired and used without a need for conscious attention. It includes procedural, associative and non-associative memory.  Procedural memory comes from repeating a process multiple times, often through skills and habits. Associative learning includes both classical and operant conditioning, which include use of rewards, punishments or reinforcers.  Non-associative learning includes habituation and sensitization processes, which is either a diminishing or intensifying response to a cue, respectively.

Realizing there are different avenues to make long term memories is important for treatment. The most basic way of viewing therapy is that it is a form of learning. Initially, explicit memory comes from skills groups in DBT where skills are taught verbally and visually with a willingness to listen, take notes, and have an open mind. While there are opportunities to participate actively in skills groups, groups are taught mostly through explicit processes. 

Commonly, those with experience in DBT programs recognize that “knowing skills” and knowing how to be effective are different experiences.  Implicit memory processes are vital for effective skills use. Any well-run DBT program will rely heavily on behavioral principles (associative), exposure to difficult emotions (non-associative) and brute repetition of skills in multiple contexts (procedural) or dedicated expectation on homework and reviewing written work.  This is likely why effective immersive residential DBT programs build a culture of care around DBT assumptions.  Combined with the heavily weighted extrinsic strategies found in outpatient skills groups, effective residential treatment also has a robust integration of intrinsic memory strategies through milieu interactions. By making use of all long-term memory strategies, clients are much quicker and effective at building a life worth living. Pacing does matter since some individuals may not be able to tolerate an intense, fast-moving residential program, but do nicely in standard outpatient DBT. 

You can increase learning through intrinsic learning strategies, e.g. willingness to complete homework, being consistent with mindfulness practice, completing Behavioral Chain Analysis for target behaviors, following limits,  and by completing exposure strategies and homework.  Strong recovery needs more than just passively listening in groups and “processing” with staff. It requires courage, hard work, , willingness for feedback, and practicing new ways of being by following unfamiliar limits that may seem unnecessary from your perspective.

And yes, skills don’t work. Usually not the first time and probably not to make you feel better now. Feeling better is not the end goal for most of the skills. Skills have a variety of goals and they work by doing them over and over and over again, even if it feels like they aren’t “working” in the moment    As a final note, mindfulness is extraordinarily necessary for treatment. For any resident who becomes stuck in treatment, nearly always they are not practicing mindfulness nearly enough.  Mindfulness gives more access to long term memory strategies, leading to more genuine, long-lasting change.