DBT Skills Training PDF

2. Planning to Conduct DBT Skills Training 31 this behavior is under control. It is also usually pref- area. The treatment model here is somewhat similar erable to treat social anxiety disorder (social pho- to a general practitioner’s sending a client to a spe- bia) before asking a c...

2. Planning to Conduct DBT Skills Training 31 this behavior is under control. It is also usually pref- area. The treatment model here is somewhat similar erable to treat social anxiety disorder (social pho- to a general practitioner’s sending a client to a spe- bia) before asking a client to join a skills training cialist for specialized treatment. group. Some clients may have already participated Individual therapists who have no one to refer in 1 year or more of a skills training group, but clients to for skills training, or who want to do it need further focused attention to one category or themselves, should make the context of skills train- set of skills. ing different from that of usual psychotherapy. For Finally, a client may not be able to attend the example, a separate weekly meeting devoted specifi- offered group sessions. In primary care settings, cally to skills training may be scheduled, or skills or when skills training is being integrated into in- training and individual therapy can alternate week- dividual therapy, skills may be taught during indi- ly. The latter choice is particularly likely to work vidual therapy sessions. In these situations, having when the client does not need weekly individual the skills handouts and worksheets readily available sessions focused on crises and problem solving. If will make it easiest for the individual practitioners possible, the skills session should be conducted in to slip skills training into the fabric of ongoing indi- a room different from that used for individual psy- vidual care. In such a case, the therapist can make chotherapy. Other possibilities include switching continuous efforts to incorporate the skills training chairs; moving a table or desk near (or between) procedures in every session. A problem with this ap- the therapist and the client to put the skills train- proach is that the rules are not clear: It is often not ing materials on; using a blackboard; turning up the apparent to the client what contingencies are oper- lighting; having skills training sessions at a different ating at any given time in an interaction. The client time of day than psychotherapy sessions, or for a who wants to focus on an immediate solution to an shorter or longer time period; arranging for audio or immediate crisis, therefore, has no guidelines as to video recordings of the sessions if this is not done in when insisting on such attention is appropriate and individual psychotherapy, or vice versa; and billing likely to be reinforced and when it is not. A problem differently. For a therapist with a particularly dif- for the therapist is that it is extremely difficult to re- ficult client, participation in a supervision/consulta- main on track. My own inability to do just this was tion group is important in keeping up motivation one of the important factors in the development of and focusing on skills. Even for those individuals DBT as it is today. who are in group skills training, a task of individual A second alternative is to have a second therapist therapists is to reinforce the use of skills and also to do individual skills training with each client. The teach skills “ahead of time,” so to speak, as needed. rules for client and therapist behavior in this case Many therapists in our clinic also give clients skills are clear. In this format, general behavioral skills homework assignments related to current problems, are learned with the skills trainer; crises manage- using the DBT skills training worksheets. ment and individual problem solving, including the application of skills learned to particular crisis or Group Skills Training problem situations, are the focus of sessions with the primary therapist or case manager. This ap- The chief advantage of group skills training is that it proach seems especially advantageous in certain is efficient. A group can include as few as two peo- situations. For example, in our university clinic a ple. In our clinic, with very dysfunctional clients, number of students are eager to obtain experience in we try to have six to eight persons in each group. working with individuals with severe disorders who Group treatment has much to offer, over and above need long-term therapy, but the students are not able what any individual therapy can offer. First, thera- to commit to longer-term individual therapy. Con- pists have an opportunity to observe and work with ducting focused skills training for a period of time interpersonal behaviors that show up in peer rela- is a good opportunity for these students, and in my tionships but may only rarely occur in individual experience it has also worked out well for the cli- therapy sessions. Second, clients have an opportuni- ents. This would be an option in any setting where ty to interact with other people like themselves, and residents, social workers, or nurses are in training. the resulting validation and development of a sup- In a group clinical practice, therapists may conduct port group can be very therapeutic. DBT encourages skills training for each other; a large practice may outside-of-­session relationships among skills group hire some therapists with specific talents in this clients, as long as those relationships—­ including 32 I. AN INTRODUCTION TO DBT SKILLS TRAINING any conflicts—can be discussed inside the sessions. gether for a period of time. If a choice is available, Third, clients have an opportunity to learn from which type of group works better? one another, thus increasing avenues of therapeutic I have tried both types of groups and believe that input. Fourth, groups typically reduce the intensity open groups work better for skills training. There of the personal relationship between individual cli- are two reasons. First, in a closed group it becomes ents and the group leaders; in dynamic terms, the progressively easier to deviate from the skills train- transference is diluted. This can be very important, ing agenda. Process issues frequently become more because the intensity of therapy sometimes creates prominent as members get more comfortable with more problems than it solves for clients who have one another. The group as a whole can begin to drift problems regulating their emotions. Fifth, if a norm away from a focus on learning behavioral skills. Al- of practicing skills between sessions can be estab- though process issues may be important and cannot lished, such a norm can increase skills practice in be ignored, there is a definite difference between a individuals who on their own might be much less behavioral skills training group and an interpersonal likely to do the skills homework practice ordinarily process group. Periodically adding new skills train- assigned weekly. Finally, skills groups offer a rela- ing group members, who expect to learn new behav- tively nonthreatening opportunity for individual cli- ioral skills, forces the group to get back on task. ents to learn how to be in a group. Second, in an open group new clients have the In my ongoing DBT research programs, we have capacity to reenergize a group or allow a change offered a variety of different treatment programs. In of norms when needed. In addition, for individuals our 1-year standard DBT program, clients in indi- with difficulty with change and/or trust, an open vidual therapy also participate in group skills train- group allows clients an opportunity to learn to cope ing. In our 1-year DBT case management program, with change in a relatively stable environment. A clients have a DBT case manager as well as group somewhat controlled but continual rate of change skills training. In our adolescent program, each ado- allows therapeutic exposure to change in a context lescent sees an individual therapist, and the parents where clients can be helped to respond to it effec- or other caregivers and the adolescent attend the tively. skills group. We also offer a 6-month skills train- ing program for friends and family members of in- dividuals who either are difficult to be with or have Heterogeneous versus difficult mental disorders. We have offered a similar Homogeneous Groups skills training group for individuals with emotion dysregulation. DBT skills training group members in my clinic are A number of issues need to be considered in set- largely (but not completely) homogeneous with re- ting up a skills group—­whether to have open or spect to diagnosis. Depending on the training needs closed groups; whether groups should be heteroge- of my students or the research studies currently in neous or homogeneous; and how many group lead- progress, we have restricted entry to individuals ers or trainers there should be and what these per- who (1) meet criteria for BPD; (2) have BPD and sons’ roles should be. I discuss these issues next. are highly suicidal; (3) have BPD with serious anger problems; (4) have BPD and substance use disorders; (5) have BPD and PTSD; (6) are suicidal adolescents Open versus Closed Groups together with their parents; (7) have disordered emo- tion regulation; or (8) are friends or family mem- In an open group, new members can enter on a con- bers of individuals with serious disorders. In most tinuing basis. In a closed group, the group is formed groups, we will also allow in one or two partici- and stays together for a certain time period; new pants who are being treated in our clinic but meet members are not allowed once the group composi- criteria for other disorders (e.g., depression, anxiety tion is stable. Whether a group is open or closed will disorders). Group members are not particularly ho- often depend on pragmatic issues. In many clinical mogeneous in other ways. Ages range from 13 to 18 settings, especially inpatient units, open groups are years in the adolescent groups and from 18 up in a necessity. In outpatient settings, however, it may other groups; some groups include clients of both be possible to round up a number of people who sexes. Socioeconomic, education, marital, and pa- want skills training and who will agree to stay to- rental statuses vary.  2. Planning to Conduct DBT Skills Training 33 With the exception of groups designed for friends tionally involved with one another’s problems and and families and for adolescents and their families, tragedies. These clients often become anxious, we prohibit sexual partners from being in the same angry, depressed, and hopeless not only about the skills training group. Sexual partners are placed into problems in their own lives, but about the problems different groups at intake. If a sexual relationship of those close to them. Thus just listening to oth- develops among two members of a group, we have a ers’ life descriptions can precipitate intense, painful rule that one must drop out. Such relationships can emotional responses. This has also been a very dif- create enormous difficulties for the partners. ficult issue for our staff members; we also have to For many of our clients so far, our group repre- listen to painful story after story from our clients. sents their first experience of being with other in- Imagine how much more difficult it is for individu- dividuals sharing very similar difficulties. Although als who have little capacity to modulate their re- from my perspective a homogeneous group is an sponses to emotionally charged information. asset in doing group skills training, the choice obvi- Another argument against homogeneous groups ously has pros and cons. of clients who have trouble regulating their emo- tions or impulses is based on the notion that in such a group there will be no one to model appropriate, Arguments against adaptive behaviors—or, similarly, that there will a Homogeneous Group be extensive modeling of inappropriate behaviors. There are a number of rather strong arguments I have simply not found this to be the case. In fact, against a homogeneous group of clients who have I am frequently amazed at the capacity of our cli- severe disorders, including severe emotion dysregu- ents to be helpful to one another in coping with lation, suicidal behaviors, or behaviors that might life’s problems. In difficult therapy protocols such elicit contagion. First, such a group for suicidal and/ as exposure-based procedures, it is not unusual for or highly impulsive individuals can be risky on an clients to help each other cope with getting through outpatient basis. Any kind of therapy, individual or the treatment. The one area where an absence of ap- group, can be very stressful for clients with disor- propriate modeling does seem to exist is in the area dered emotion regulation. Extreme emotional re- of coping with extreme negative feelings. Especially activity all but ensures that intense emotions will with suicidal individuals at the beginning of treat- be aroused, requiring skillful therapeutic manage- ment, it is often necessary for the group leaders to ment. A therapist has to be very good at reading and take much of the responsibility for modeling how to responding to nonverbal cues and indirect verbal cope with negative emotions in a nonsuicidal man- communications—a difficult task under the best of ner (see Chapter 5 of this manual). circumstances. Therapeutic comments can be misin- A fourth argument against homogeneous terpreted, or interpreted in a way that the therapist groups—­ particularly with individuals who have did not mean, and insensitive comments can have a BPD or major depression—has to do with their strong impact. passivity, their ability to “catch” other’s moods These problems are compounded in group therapy. and behavior, and their inability to act in a mood-­ It is impossible for therapists to track and respond independent fashion. Contagion of suicidal behavior individually to each group member’s emotional re- can be a particularly difficult problem. At times, if sponses to a therapy session. With more clients and one group member comes to a session in a discour- a faster pace than in individual therapy, there are aged or depressed mood, all members of the group more opportunities for therapists to make mistakes will soon be feeling the same way. If group leaders and insensitive remarks, as well as for clients to mis- are not careful, even they can sink down with the construe what is going on. In addition, it is more dif- members. One of the reasons why we have two lead- ficult for clients to express their emotional reactions ers for each group in our clinic is that when this to a group therapist in front of other group mem- happens, each therapist will have someone to keep bers. Thus the possibility for clients leaving in tur- him or her functioning at an energetic level. It can moil, with emotional responses they cannot handle, be very difficult. is greatly increased in group over individual therapy. Finally, it is sometimes said that some client pop- A second, related drawback to homogeneous ulations (e.g., adolescents or those with BPD) are groups has to do with the tendency of clients with more prone to “attention seeking” than are other high emotion regulation problems to become emo- clients, and that this tendency will be disruptive to 34 I. AN INTRODUCTION TO DBT SKILLS TRAINING any group process. Once again, I have not found course, a threatening experience for a person who is this to be the case. working hard at avoiding dysfunctional patterns of behavior. In addition, we have found that as clients progress in therapy, they often begin to change their Arguments for a Homogeneous Group self-image from that of “person with a disorder” to From my perspective, there are two powerful argu- that of “normal person.” Especially if they are very ments for a homogeneous group. First, homogeneity judgmental, they can find it very hard to stay in a allows the group leaders to tailor the skills and theo- group defined as a group for disordered individuals. retical conceptions they offer to the specific prob- These two issues—the urge to imitate dysfunctional lems of group members. Most of the skills taught behavior, and the need to change one’s self-image are applicable for many client populations. Howev- from “disordered” to “not disordered”—must be er, a heterogeneous group requires a much more ge- dealt with effectively by the group leaders if an indi- neric presentation of the skills, and the application vidual is to continue with the group. of the skills to each person’s central problems has to be worked out individually. With a homogeneous group, examples can be given that reflect their spe- Clarifying Providers’ Roles cific problems and situations. A common conceptual Skills Group Leaders scheme would be difficult to present in a heteroge- neous group unless it was very general. In standard DBT groups, we use a model of a pri- A second argument for a homogeneous group is mary group leader and a co-­leader. The functions the opportunity for clients to be with a group of indi- of the two leaders during a typical session differ. viduals who share the same problems and concerns. The primary leader begins the meetings, conducts In my experience, this is a very powerful validating the initial behavioral analyses of homework prac- experience for our clients. Many have been in other tice, and presents new material about skills. The pri- groups but have not had the experience of being mary group leader is also responsible for the timing around others like themselves. For those with BPD of the session, moving from person to person as time and other severe disorders, they may have finally allows. Thus the primary group leader has overall found others who actually understand the often in- responsibility for skills acquisition. explicable urges to injure themselves, the desire to The co-­leader’s functions are more diverse. First, be dead, the inability to regulate anger, the power he or she mediates tensions that arise between mem- of urges to use drugs, the inability to pop out of a bers and the primary leader, providing a balance depressed mood, the frustration of being unable to from which a synthesis can be created. Second, while control emotions and behavior, or the pain of emo- the primary group leader is looking at the group as a tionally invalidating experiences. Adolescents have whole, the co-­leader keeps a focus on each individ- found others who understand their difficulties with ual member, noting any need for individual atten- parents, the pain of being bullied, their intense desire tion and either addressing that need directly during to be acceptable, and their beliefs that they are not. group sessions or consulting with the primary leader In a group for friends and family members, clients during breaks. Third, the co-­leader serves as a co-­ share the pain of having loved ones suffering and the teacher and tutor, offering alternative explanations, frequent sense of desperation and helplessness. examples, and so on. The co-­leader may move his A factor that can complicate the advantage of or her seating around the group as needed to assist having an entire group of individuals with the same participants in finding the right handouts or work- disorder or problem has to do with different rates sheets or to provide needed support. The co-­leader is of individual progress in treatment. When one cli- often the person who keeps track of the homework ent is engaging in dysfunctional behaviors, it is very assignments. This is especially important when spe- validating to have other group members struggling cial individual assignments are given to one or more with the same issue. However, once the client has participants in the group. In these cases, it is also stopped such behaviors, it can be very hard if oth- the co-­leader who is charged with remembering the ers are still engaging in the same behaviors. Hear- various assignments. ing about others’ out-of-­control behavior seems to Generally, if there is a “bad guy,” it is the primary cause a greater urge to do the same thing; this is, of group leader, who enforces the group norms; if there