DBT Skills Training Limits PDF

58 I. AN INTRODUCTION TO DBT SKILLS TRAINING rules. Other limits that must be observed are those ing as needed during his or her shift, or (as is done of the skills trainers as individuals and (in a group in some settings) may have regular office hours for context) of the group as a...

58 I. AN INTRODUCTION TO DBT SKILLS TRAINING rules. Other limits that must be observed are those ing as needed during his or her shift, or (as is done of the skills trainers as individuals and (in a group in some settings) may have regular office hours for context) of the group as a whole. skills coaching on the unit. In my experience, the best way to communicate phone limits is by discussing the important role of Limits of Skills Training Itself the individual psychotherapist in the total DBT pro- The key limitation of DBT skills training is that the gram, and pointing out that skills trainers do not skills trainers do not function as individual thera- duplicate the individual psychotherapist’s job. In our pists during skills training sessions. The role of experience, clients grasp this rule very quickly and skills trainers is clearly defined and limited to teach- rarely violate it. If a client is in a skills-only program ing behavioral skills and dealing with the interper- and does not have an individual therapist, then call- sonal relationships that arise in sessions. A skills ing the local crisis line should be recommended, as trainer is like a university professor or a high school these services are ordinarily very good. If necessary teacher. “Personal” calls texts, or e-mails to skills and possible, you might want to provide the crisis training leaders are acceptable only under certain line personnel with a coaching plan for specific cli- conditions: Clients may contact the skills trainers if ents. We have done that in our clinic with very good they will not be able to attend a group session for results. Most phone calls, texts, and e-mails other some reason, or if they have a serious interpersonal than session cancellations revolve around their rela- problem with a trainer or group member that can- tionships with skills trainers or (in a group context) not be resolved in a session. with other group members. At times, a client may There are three exceptions to these coaching lim- make contact to find out whether a trainer hates him its. The first is when a skills training client is also or her and wants the client out of skills training. At receiving DBT individual psychotherapy from an- other times, a client may call to discuss how it is other therapist in the same clinical setting. In these completely impossible to continue in skills training instances, a skills training leader serves as a backup any longer, since sessions are so painful. Relation- therapist for the individual therapist. Thus, when ship problem-­solving strategies must be implement- the individual psychotherapist is out of town, it is ed by the skills training leaders during such phone appropriate for the client to call the skills trainer calls. These are discussed in detail in Chapter 15 of under the same circumstances that he or she would the main DBT text and in Chapter 5 of this manual. call the individual therapist. When the reason for In a skills-only group, such as the friends-and-­family the call is to discuss interpersonal relationships in group in our clinic, phone calls to the skills trainers the skills training, there are some limits. These lim- to discuss life problems and repeated requests for its are the natural limits of the skills training leader, individual time with the skills trainers surrounding and thus the ordinary strategies of observing lim- skills training sessions should alert the skills train- its in individual therapy apply. It is essential that a ers that such clients may need more help than can skills training leader in this situation understand be given in skills training. In these cases, individual these phone limits and communicate them clearly to therapy may be recommended and referrals given. the clients. The second exception is in multifamily A second limit during the first year of DBT skills skills training for adolescents who are also in indi- training is that personal crises are generally not dis- vidual DBT. In these situations, the adolescent calls cussed in skills training sessions. This limit is made the individual therapist for coaching, and the par- crystal clear for the first several sessions and is re- ent or other family member in skills training can clarified thereafter when clients wish to discuss their call the skills trainer for coaching. The reason for current crises. If a crisis is extreme, of course, skills this is that often coaching is needed for managing training leaders may choose to violate the rule. To the relationship with one of the other persons in the cite a very extreme example, when a group mem- treatment (i.e., the adolescent with a parent, or vice ber in our clinic was raped on her way to a group versa). A conflict arises when the same person is session, we of course discussed it. A death in the coaching both parties and disagreements arise. The family, a divorce, a breakup of a relationship, or a third exception is when a skills trainer is teaching rejection by a therapist may be reported and briefly skills on an inpatient or residential unit and is also a discussed at the beginning of sessions. milieu skills coach before and after sessions. In these The key to getting individuals with disordered situations, the skills trainer may give ad hoc coach- emotion regulation to follow this rule is the way in  3. Structuring Skills Training Sessions 59 which crises are dealt with. Generally, any topic can training because they have very difficult people in be discussed if the focus is on how the client can their lives. It is natural for them to think that a skills use the skills being learned to cope with the crisis. class can teach them how to get those difficult per- Thus, although at first glance it would appear that sons to be less difficult. Although this very likely the “crisis of the week” cannot be discussed, at sec- may be a result of the individuals’ learning the skills ond glance it is obvious that it can be, as long as it is taught in skills training, it is not the focus. discussed within the context of DBT skills. This ori- It is often helpful here to tell the “rainmaker” entation, however, is not always the orientation that story. A Native American tribe was in the fifth year a person is hoping for. Rather than giving clients of a terrible drought. All the crops were failing, and free rein to discuss their problems and to share all the people were in danger of starving. The tribe in- the details, skills training leaders very quickly inter- vited a rainmaker to come to bring the rain. When vene to highlight the relationship of these problems the rainmaker arrived, he went into the tepee set up to the particular skill module of the moment. for him. After the first night had passed, the people For example, if an individual psychotherapist has expected him to come out and start his rainmaking, terminated a client or a client has been fired, this but he did not. After 3 days, he still had not come can be dealt with in terms of the interpersonal ef- out. The elders of the tribe then went into the tepee fectiveness skills the client can use to find out why, and asked, “When are you going to start making the to find a new therapist or new job, or to get the ther- sky bring down rain?” apist or job back. It can also be approached from The rainmaker said, “I am bringing myself into the standpoint of how hurt the client is feeling in order. When I come into order, the tribe will come response to the rejection and how the client can use into order. When the tribe comes into order, the emotion regulation skills to feel better. If core mind- fields will come into order. When the fields come fulness skills are the focus, the client can be encour- into order, the sky will come into order. And when aged to observe and describe the event and his or her the sky comes into order, it will rain.” responses. The client can also be helped to notice This story has always reminded me of a woman any judgmental thoughts and how to focus on what who took our skills training class. She had a daugh- works rather than on revenge. Finally, the problem ter who had very severe BPD. The mother met me can be approached in terms of how the person is some time later and said, “When I learned the DBT going to survive it or tolerate it without engaging skills, I was transformed, and when I was trans- in impulsive destructive behaviors. Most problems formed, my daughter was transformed.” It is this lend themselves to an analysis in terms of each of the point of view that skills trainers must continue to skill modules. Noninterpersonal situations, which explain and support. at first glance may seem inappropriate for the Inter- Finally, the limits of structured skills training personal Effectiveness module, can be looked at as may have to be observed in regard to process issues. opportunities for finding friends to share with and The group leaders need to carefully communicate for obtaining the social support the client needs to the limits on process issues, individual crises, and cope with the problem. Skills trainers must be vigi- general life discussions in a skills training program lant in always bringing the crisis back to the skills. versus a psychotherapy process group. (The ten- When the skills seem ineffective or insufficient for dency to favor process discussions and work on in- the problem, clients in individual therapy should be dividual crises is, as I have noted previously, much encouraged to talk with their therapists. more pronounced when skills training is conducted A third limit is that skills training sessions are individually; this is a principal reason for conduct- focused on increasing the skills of the individuals ing skills training in groups.) attending the sessions. The focus is not and cannot be on how to change other people in clients’ lives. Personal Limits of Skills Training Leaders Although interpersonal effectiveness skills are often aimed at changing what other people do, the focus The observing-­limits approach with respect to the even there is on the clients’ learning the skills and skills training leaders is no different in DBT skills being able to use them, not on how effective they are training than it is in other components of DBT. Es- at changing people the clients want to change. This sentially, it is the task of the leaders to observe their is a particularly critical limit in our friends-and-­ own limits in conducting the treatment. In my expe- family groups. Here the individuals come to skills rience, the crucial limit that must be observed has to 60 I. AN INTRODUCTION TO DBT SKILLS TRAINING do with phone calls. Skills trainers must track their careful in this situation not to punish the member own ability to handle lengthy interpersonal discus- for leaving on the one hand, and to punish him or sions with clients and must communicate their lim- her for staying on the other. Dialectical balance is its clearly to the clients. crucial, since the leaders also want to encourage the member to stay at a session and inhibit maladaptive behaviors as long as possible. Limits of a Group as a Whole The key limit of DBT skills training groups when References clients have severe problems with emotion regula- tion is that they cannot tolerate hostile attacks in 1. Dimeff, L. A., & Koerner, K. (Eds.). Dialectical be- sessions. My colleagues and I have had to make it havior therapy in clinical practice. New York: Guil- very clear to group members that behaviors such ford Press. as throwing things, destroying property, and at- 2. Mintz, R. S. (1968). Psychotherapy of the suicidal tacking or harshly criticizing other group members patient. In H. L. P. Resnik (Ed.), Suicidal behaviors: are proscribed. When a group member engages in Diagnosis and management (pp. 271–296). Boston: hostile behavior, the group member is encouraged Little, Brown. to work on the problem with his or her individual 3. McMain, S. F., Guimond, T., Habinski, L., Barnhart, psychotherapist (if the person has one) or with a R., & Streiner, D. L. (2014). Dialectical behaviour therapy skills training versus a waitlist control for self skills trainer after the group session. However, it is harm and borderline personality disorder. Manuscript preferable for an individual to leave a group session submitted for publication. (even if only temporarily) than to engage in these behaviors. The group leaders, of course, have to be