Skills Training Managing Homework PDF

4. Skills Training Treatment Targets and Procedures 75 lyzed and discussed as such. The problem should be in Chapters 3, 8, and 10 of the main DBT text; the framed in such a way that whatever skills are cur- behavioral validation strategies described in that rently being taug...

4. Skills Training Treatment Targets and Procedures 75 lyzed and discussed as such. The problem should be in Chapters 3, 8, and 10 of the main DBT text; the framed in such a way that whatever skills are cur- behavioral validation strategies described in that rently being taught can be applied. text’s Chapter 8 and in this manual should be used in skills training as well (see also Interpersonal Ef- fectiveness Handouts 18 and 19). I discuss these top- Creating an Environment That Reinforces ics further in the skills module content chapters of Skilled Behavior this manual (Chapters 7–10). Individuals differ in styles of self-­regulation. On the continuum whose poles are internal self-­regulation Family and Couple Sessions and external environmental regulation, many indi- viduals with high dysregulation of emotions and as- One way to maximize generalization is to have indi- sociated actions and thoughts are near the environ- viduals from the clients’ social community learn the mental pole. Many therapists seem to believe that DBT skills. Usually, these will be members of the the internal self-­regulation pole of the continuum is clients’ families or their spouses or partners. In ado- inherently better or more mature, and spend a fair lescent DBT programs, for example, as noted previ- amount of therapy time trying to make individuals ously, skills training ordinarily includes parents or with emotion dysregulation more self-­regulated. Al- other family care providers. Trainers can give clients though DBT does not suggest the converse—that copies of the skills handouts to take home to teach environmental regulation styles are preferable—it their family members and/or friends the skills. Thus does suggest that going with the clients’ strength is all members of a family can be learning the same likely to be easier and more beneficial in the long sets of skills, and can practice together and coach run. Thus, once behavioral skills are in place, clients each other. Family members of clients with emo- should be taught how to maximize the tendency of tion dysregulation have been very receptive to this their natural environments to reinforce skilled over type of therapy. Skills training can also be offered unskilled behaviors. This may include teaching them for friends and family members of adults who are how to create structure, how to make public instead in the DBT treatment program. In these situations, of private commitments, how to find communities clients and their family members may be in separate and lifestyles that support their new behaviors, and groups. how to elicit reinforcement from others for skilled rather than unskilled behaviors. (See Distress Toler- Use of Fading Principles ance Handouts 19 and 20.) This is not to say that cli- ents should not be taught self-­regulation skills; rath- At the beginning of skills training, the trainers er, the types of self-­regulation skills taught should model, instruct, reinforce, give feedback, and coach be keyed to their strengths. Written self-­monitoring the clients for using skills both within the therapy with a prepared diary form, for example, is pref- sessions and in the natural environment. If skillful erable to trying to observe behavior each day and behavior in the everyday environment is to become make a mental note of it. Keeping alcohol out of independent of the trainers’ influence, however, the the house is preferable to trying a self-talk strategy trainers must gradually fade out use of these proce- to inhibit getting out the bottle. It is easier to diet if dures, particularly instructions and reinforcement. a client eats at home rather than out at restaurants The goal here is to fade skills training procedures that serve yummy but huge meal portions. Using an to an intermittent schedule, such that the trainers alarm to wake up can be more effective than count- are providing less frequent instructions and coach- ing on oneself to wake up when needed. ing than clients can provide for themselves, and less A final point needs to be made here. Sometimes modeling, feedback, and reinforcement than clients clients’ newly learned skills do not generalize be- obtain from their natural environments. cause out in the real world clients punish their own behavior. This is usually because their behavioral expectations for themselves are so high that they Managing Review of Skills simply never reach the criteria for reinforcement. Practice Homework This pattern must change if generalization and prog- ress are to occur. Problems with self-­reinforcement It is important to remember that DBT is a problem-­ and self-­punishment are discussed more extensively focused treatment with two core intervention strat- 76 I. AN INTRODUCTION TO DBT SKILLS TRAINING egies: validation and problem solving. Both are in applying a skill in a particular situation are fur- important in managing homework review. When ther opportunities for group solution analysis. Al- trainers are reviewing homework, the strategy is to most always, someone will already have solved the validate when the assigned skills are practiced cor- problem at hand for him- or herself; thus the group rectly and effectively—and to problem-solve when leaders should be especially careful in the solution no homework is done, the skills are not practiced analysis phase not to jump in with solutions before correctly and/or effectively, and/or problems in eliciting possible solutions from other group mem- using the skills are identified. Even for clients who bers. However, they should not be reluctant to offer are eager to learn, who read the skills book at home, a solution or a particular application of a skill, even and who practice the skills religiously, problems in if other group members have offered other ideas. correctly and effectively using the skills can arise. Managing the sharing of between-­session practice Thus it is important not to cut this review time in requires enormous sensitivity on the part of the lead- favor of more time for teaching new skills in the sec- ers. The tasks here are to prod each client gently to ond half of the session. analyze his or her own behavior; to validate difficul- Problem solving is a two-stage process: (1) under- ties; and to counter tendencies toward judging nega- standing the problem at hand (behavioral analysis) tively and holding the self to impossibly high stan- and (2) attempting to generate new, effective use dards. At the same time, leaders help clients develop of the skills (solution analysis). Understanding the more effective skill strategies for the coming week if problem at hand requires defining problems in using needed. The leaders must be adept at alternating at- the skills, highlighting patterns and implications of tention between the previous week’s behaviors and current skills use, and developing hypotheses about in-­session attempts to describe, analyze, and solve factors interfering with effective use of the skills. The problems. Shame, humiliation, embarrassment, self-­ second stage, that of targeting change, requires pro- hatred, anger, and fear of criticism or looking “stu- viding feedback on correct implementation of skills pid” are common emotions interfering with the abil- when needed; developing solutions to the problems ity to engage in and profit from homework review. that have arisen in using skills; and encouraging ef- Deft handling of these emotions is the key to using forts to practice the skills by providing the rationale practice sharing therapeutically; it involves combin- for using skills and troubleshooting implementation ing validating strategies with problem-­solving strat- of solutions. The aim of this repeated focus on ana- egies, and irreverent communication with reciprocal lyzing and problem-­solving difficulties is not only communication. (See Chapter 5 of this manual for to get clients to begin using the skills effectively, more on validation and communication strategies.) but also to get clients to begin using the problem-­ The first step in practice sharing is for each group solving strategies with one another and eventually member to share with the group the particular skills with themselves. he or she used (and the success or failure of these To a large extent, skills training is a general case efforts), as well as the situations the skills were used of solution analysis. Skills are presented as practical in during the previous week. Clients will inevitably solutions to life’s problems, and the potential effec- present their situations and/or skill use in very gen- tiveness of various skills in particular situations is eral and vague terms at first. They will also often discussed during each meeting. Perhaps more than describe their inferences of others’ motives or emo- any other set of strategies, solution analysis utilizes tions, or their judgmental beliefs, as if these infer- the power of a group context. Each member should ences and beliefs are facts. The task of a skills train- be encouraged to offer solution ideas to other group er is to engage a client in the strategy of behavioral members and to help develop strategies to solve the analysis. In other words, the task is to get a client problems described. For example, a member who to describe (using the mindfulness “what” skill of is having trouble paying attention during group describing) the particular environmental and behav- sessions and getting homework assignments into ioral events leading up to the problem situation and short-term memory can be helped to think of ways to the successful or unsuccessful attempt to use the to attend more closely. The group as a whole can skills. almost always be counted on to come up with many Obviously, providing such a description requires solutions to not remembering to practice during the that a client be able to observe during the week. week. Difficulties in selecting the right skill to use or Often clients have great difficulty describing what  4. Skills Training Treatment Targets and Procedures 77 happened because they are not astute observers; When the Skills Did Not Help however, with repeated practice and repeated re- If a client could not use the skills being taught, or inforcement over the weeks, their observation and reports using the skills but not getting any benefits description skills tend to improve. A minute descrip- from them, the leaders use problem-­solving strate- tion allows a trainer to assess whether a client in fact gies such as behavioral analysis to help the client used the skills appropriately. If the client has prac- analyze what happened, what went wrong, and how ticed and the skills have worked, he or she should be he or she could use the skills better next time. It supported and encouraged by the leaders. The cli- is extremely important at this point to lead the cli- ent models for other clients how they can use those ent through a detailed examination of just what did same skills for similar problems. Thus the leaders occur. This can be torturous, because almost always should try briefly to elicit from other group mem- (especially during the first several months of therapy) bers examples of either similar problems or similar clients are fearful of skills trainers’ and other mem- skill usage to foster this generalization. Client-to-­ bers’ judgments, and are also judging themselves in client praise and encouragement are reinforced. It is negative ways. Thus they can be expected to be very very important to get each client to describe in detail inhibited. Sometimes a client will jump right in with his or her use of the skills in that particular week’s a notion of why a skill didn’t work or why he or problematic situations. The same amount of atten- she couldn’t apply it, without examining the actual tion to detail must be given to the week’s successes events. These explanations are frequently pejorative as to the week’s difficulties. In addition, over time and involve name calling (e.g., “I am just stupid”). the leaders can use such information to identify the Or a client may accept without question the premise client’s patterns in skill usage. that his or her situation is hopeless and skills will The insight strategies can also be used. During never help. Emotionally dysregulated people are homework sharing, it is very important to look rarely able to analyze objectively and calmly what carefully for patterns in situational problems, as led up to a particular problem, especially when the well as typical responses to such problems. High- problem is their own behavior. Obviously, if they lighting idiosyncratic patterns can be especially cannot conduct such an analysis, attempts to solve helpful in future behavioral analyses. This is espe- the problem are probably doomed from the start. cially important if a client is consistently reporting Many are unable to see the critical role of environ- only one skill strategy. For example, in one of my mental context in behavior and persist in viewing groups I had a client who always tried to change all behavior as a function of internal motives, needs, problem situations as his primary method of emo- and the like. (It is, of course, essential that skills tion regulation. Although his skills at problem-­ trainers not collude with this view.) Thus the skills solving situations were excellent and commendable, trainer’s task here is to engage the client in a behav- nonetheless it was also important for him to learn ioral analysis; to model nonpejorative, nonjudgmen- other methods (e.g., tolerating the situation, dis- tal behavioral evaluations; and (in a group context) tracting himself). Skills trainers should comment to get both the individual and the group engaged on any rigid patterns that they see, as well as on in the process so that the same skills can be used effective patterns or skills that the clients use. Cli- in other problem situations. (How to do this, where ents’ observations and comments about their own to start and stop, and roadblocks to avoid are de- or one another’s skillful patterns should, of course, scribed in detail in Chapter 9 of the main DBT text.) be noted and reinforced. (It is essential to follow the Over time, it is important to encourage and re- guidelines provided in the insight section in Chapter inforce clients in helping one another analyze and 9 of the main DBT text.) solve difficult problems. Not every problem situation can be changed. My experience is that when given a limited amount of time to share, clients with disordered emotion reg- When a Client Has Difficulty ulation will almost always share their successes in with Homework using skills, and will rarely want to describe their problems and failures. Thus listening carefully to During sharing, a client will often report that he the successes is even more important than it might or she did not practice at all during the preceding be with other populations. week. It would be an error to take this comment at 78 I. AN INTRODUCTION TO DBT SKILLS TRAINING face value. On close examination, we often find that al. Leaders must be cautious, however, in assuming the client did practice; he or she just did not actu- a skill doesn’t fit the particular client. Inexperienced ally solve the problem. The discussion then turns to leaders often give up on a skill too easily. They may the issue of shaping and setting appropriate expecta- assume that the specific skill is not a good match for tions. Often we find that the client does not have a a specific group member when, in actuality, the cli- complete understanding of how to practice the skill ent has not been applying the skill properly. assigned. Or we may find that the person does not understand many of the skills discussed previously, When a Client Did Not Do Any but has been afraid to ask questions. In these in- Homework Practice stances, both the self-­censoring of questions and the problem in homework practice should be discussed. Almost all incidents of noncompliance with home- Whenever possible, it is useful to ask other clients work assignments (i.e., refusing or forgetting to to help the person having difficulty. In the case of practice skills) and of refusal or failure to engage in interpersonal effectiveness, we may ask another cli- skills training activities should elicit an immediate ent to role-play how he or she would cope with the movement into behavioral analysis with the client situation. Emotion regulation and distress tolerance involved. The clients’ tendency to offer simple solu- do not lend themselves to demonstration, but other tions and answers must be counteracted. Common clients can share how they have coped (or would reasons given by clients for not practicing include cope) with similar situations. not wanting to, not remembering, and not having Sometimes a client reports that he or she tried to an occasion to practice. Rarely can they identify the use the skills but could not carry them out. Chaos situational factors influencing their lack of motiva- in the environment, lack of skills, or not under- tion, failure to remember, or inability to observe standing the assignment or instructions can be im- practice opportunities. Individuals with disordered portant influences. For example, a client may enter emotion regulation tend to use punishment, com- an interpersonal situation with every intent of ap- monly in the form of self-­denigration, as a form of plying some of the interpersonal effectiveness skills behavior control. It is, of course, important that the learned previously, but then may get confused and leaders resist the temptation to collude with clients forget what to say or how to respond to a particular in punishing themselves for not practicing. Mem- remark by the other person. At other times, a cli- bers who have not attempted to practice during the ent may report using the skill appropriately, except preceding week will often not want to discuss the that it didn’t work. Even the most skilled negotiator reason for not practicing and will ask the leaders cannot always get what he or she wants; relaxation to go on to the next person. It is essential that the exercises, even when used correctly, do not always leaders not be convinced to do this. The analysis of lead to reduction of anxiety and tension. In these not doing homework can be very important. In the instances, it is essential to get precise information case of a person who is avoiding the topic because about what happened. A client and a trainer may of fear or shame, it offers a chance to practice op- both be tempted to skip this and decide that this posite action, a skill taught in the emotion regula- particular skill is not useful for this particular cli- tion module. It also offers other group members an ent. Although this may be true, it may also be true opportunity to practice their own behavior manage- that the client is not applying the skill in the correct ment and problem-­solving skills within the context way. At each point in the analysis, the trainer should of the group. be open to almost any problem. No matter what, The first step is to get a precise definition of the the trainer should treat each problem as one to be behaviors missing, followed by problem solving to solved and jump immediately to “How could you avoid the same problem in the future. (See missing solve that?” links analyses in Chapter 6 of this manual for step- Finally, sometimes a client who says he or she did by-step instructions.) Ask the following questions in not practice actually did practice, but either did not order: realize it or used skills learned outside skills train- ing. This information can be missed completely if 1. “Did doing your homework get into short- the patient’s experiences during the week are not ex- term memory?” This means “Were you aware of the plored in enough depth. assignment?” If the answer is no, there is no point in In general, what works for whom is very individu- trying to solve any other problem. Non-­awareness  4. Skills Training Treatment Targets and Procedures 79 may be due to inattention in the session, absence actions, which the client then flees from. It is very from the session, and/or not reading or getting the important to communicate to clients that it is OK to reminder of the homework. If this is the problem, have hopeless beliefs, and that the skills trainers will solutions for how to find out and know the assign- not feel invalidated if the clients do not have perfect ment must be found. If the client says yes, move to trust in them. Although each of these beliefs may be the next question. perfectly reasonable (and should be validated), hold- 2. “Were you willing to do the needed or expect- ing on to the beliefs is probably not useful, and thus ed effective behavior?” If the answer to this ques- cheerleading (see Chapter 8 of the main DBT text), tion is no, ask what got in the way of willingness cognitive modification (see Chapter 11 of the main to do effective behaviors. Ideas might include will- DBT text), and solution analysis (see Chapter 5 of fulness, feeling inadequate, or feeling demoralized. this manual) are in order. Problem-solve what got in the way of willingness— Failures in motivation and in memory offer im- for example, to practice radical acceptance, do pros portant opportunities for the leaders to teach prin- and cons, or practice opposite action. If the client ciples of behavioral management and learning. (See says yes, move to the third question. this manual’s Chapter 8, especially Section XVII.) 3. “Did the thought of doing your homework The goal over time is to use these principles to re- ever come into your mind?” If no, work on develop- place the judgmental theories based on willpower ing ways to get the thought of homework to come and mental illness that individuals with emotion into mind. (Get the group to generate lots of ideas.) dysregulation often hold. Failure to practice is a If the answer is yes, move to the fourth question. problem to be solved. 4. “What got in the way of doing your home- work once you thought of it?” If “I’ll do it later” Improving Compliance showed up, ask whether the thought of doing the with Between-­Session Skills Practice homework returned at a later point. If not, as above, work on how to get the idea to show up again. If yes, I have found the following strategies useful in help- analyze what happened then. If willfulness showed ing group members improve the frequency of skills up (“No! I’m not going to do it!”), work on solving practice between sessions. that problem. (Be open to the likelihood that will- fulness may stay around for a while.) Don’t use will- 1. Give specific assignments. When you are as- fulness to treat willfulness. signing homework, give very specific assignments. In addition, provide a homework assignment cal- endar for clients to write down assignments, and Analyzing Motivation to Complete worksheets for clients to write down the results of Homework Practice their practice. Send e-mails, text messages, or other A frequent comment that requires careful analysis reminders during the week to remind everyone of is “If I didn’t do it, I must not have wanted to do the assignments. it.” Motivational interpretations are often learned 2. Give clients a choice of worksheets. On the in previous therapies, even when they have little to website for this book, there are usually at least two do with reality. Even if the problem is one of motiva- worksheets for each assignment. I have found that tion, the question of what is interfering with motiva- clients have very specific likes and dislikes when it tion must be addressed. The most important thing to comes to worksheets. Some like to write a lot, and remember here is to offer nonpejorative hypotheses some don’t. I have developed a series of worksheets and communicate to the client a nonjudgmental at- for almost every skills handout, so that clients can titude; the client is usually judgmental enough. Hy- have a greater sense of control over what they actu- potheses that are particularly worthy of exploration ally practice and write down. include hopelessness that the skills will do any good; 3. Reinforce completion of homework. This can hopelessness that the client can ever learn the skills; be done by giving out a tangible reward that fits the beliefs that he or she doesn’t need the skills and al- group you are teaching. We give out one sticker for ready has them; and beliefs that he or she should each worksheet a client completes between sessions. have learned these skills earlier, and therefore is in- If for some reason a client did not have access to adequate or stupid for having to learn them now. the assignment, then filling out any worksheets will Such beliefs probably lead to negative emotional re- be given the same number of stickers. A secondary 80 I. AN INTRODUCTION TO DBT SKILLS TRAINING outcome of this strategy is that it cuts off almost 5. Start the review of homework with one or two any good reason for not doing any homework skills who haven’t done it. Ask at the beginning of the ses- practice. If you want to give an arbitrary reinforcer sion who has and has not done the homework. Start for homework, such as a sticker, you have to be spe- with those who have not done it, and ask the series cific in telling clients exactly how much practice is of questions listed above. For the average client, the needed to get the reward. Awarding stickers has had analysis of not doing homework is somewhat aver- a remarkable effect on increasing homework com- sive, despite your efforts to do it in a nonaversive pliance in our clinic and in other clinics we know manner. This aversive review of homework noncom- of. As noted previously, clients in our groups love pletion, however, can be very motivating and should the stickers and often bring in their favorites to add not be skipped, no matter how much the clients try to our stock. They put them on the outside of their to get you to skip it. However, you can at times end skills binders. Other groups give out candy. Vouch- the review as soon as you determine that the clients’ ers that can be exchanged for a range of tangible refusal to proceed or willfulness about it will make rewards can also be effective. As in programs for it difficult to proceed. In general, my policy is to go substance use disorders, you might be able to get to the next person or topic whenever a client refuses community merchants to donate to a gift locker to to respond. What I do not do is skip asking the client use in these programs. to respond (always in a tone of voice that implies I 4. Do not give the reward if the client did not have forgotten that they do not want to be asked). In complete the requisite homework. This point is essence, I put clients’ requests that I skip them on an critical. Many clients will become very distressed, extinction schedule. The exception here is the per- angry, sad, or tearful when they do not get a re- son who has made it abundantly clear that he or she ward. It may seem much easier just to give the re- is not participating in homework review or in the ward anyway, but this is a mistake. Once you do group as a whole. With such an individual, I might this several times, the function of the stickers as say in homework review, “Are you still not doing contingent on doing homework practice will be lost. homework [or not sharing homework]?” Or I might Those doing their homework for stickers may then say, “Are you still on strike?” If there is no answer or become distressed. If you want to reinforce other the answer is yes, I might go on or I might say, “Well, behaviors (e.g., trying hard), you can give out other I want you to know my hope springs eternal.” rewards. For example, I give out a verbal “10,000 6. Jump to those who have done homework after gold stars” (and sometimes an extravagant “12,000 analyzing one or two who haven’t. Do this when or 13,000”) at intervals whenever someone engages more than two out of eight clients have not done in behavior I want to be sure to reinforce. Although their homework. Be sure to reinforce any and all the stars are purely verbal, clients seem very willing homework done. Listening to homework reports to work for them. I began doing this in skills groups and getting others in the group to listen are crucial when a client petulantly said in a group session that here. Give needed feedback, and try to involve other she had heard I give out gold stars in other settings, group members in discussing homework. Relate one and she wanted to know why I never gave them out person’s use of skills or difficulties to those of others in the skills group. in the group when possible.