DBT Skills Training PDF

2. Planning to Conduct DBT Skills Training 37 Consultation between DBT Individual on behalf of a client. Thus therapists must be careful Providers and Skills Trainers not to fall into the trap of serving as intermediaries...

2. Planning to Conduct DBT Skills Training 37 Consultation between DBT Individual on behalf of a client. Thus therapists must be careful Providers and Skills Trainers not to fall into the trap of serving as intermediaries for a client. (See Chapter 13 of the main DBT text Communication between individual DBT provid- for a discussion of consultation-to-the-patient strat- ers and skills trainers is exceptionally important. If egies; they are also discussed briefly in Chapter 5 of the expectations of each group of providers for the this manual.) other are not spelled out and frequently reviewed, it is very likely that the two treatments will not en- When the Primary Provider hance each other. Among the most important as- Is a Skills Trainer pects of DBT are the DBT consultation team strate- gies (described in Chapter 13 of the main DBT text). It is not uncommon that skills trainers are also in- These strategies require all DBT therapists to meet dividual therapists or case managers for some of on a regular basis. The goals of these meetings are to the clients in a skills training group. Less often, a share information and to keep therapists within the pharmacotherapist may also be a skills trainer for framework of DBT. his or her clients. When either of these is the case, In my clinic, a consultation meeting is held each it is important to keep roles clear. In other words, week for 1–1.5 hours. During the meeting, skills when one is teaching skills it is important to focus trainers review for the team which skills are the cur- on skills, and to wait until after the skills session rent focus of group sessions. When necessary, the ends to revert to one’s other role. This is not only skills trainers actually teach the other team mem- because of time constraints in a skills class, but also bers the skills. In this context, it is helpful for clients because as soon as skills trainers start managing if their primary providers and skills trainers share a crises, individual clients (particularly those whose common language in discussing application of be- lives involve constant crises) are likely to bring up havioral skills. This also decreases the potential for more crises to discuss and problem-solve. Focusing confusion. Although consistency and conformity on learning new behaviors can take a lot more effort between various treating agents are not particularly than sitting back and discussing the crises of life. valued in DBT, such consistency here can be useful, since the number of new skills to be learned is quite large. The weekly meetings increase this commu- DBT Skills Training nality. In addition, any problems individual clients outside Standard DBT may be having in applying skills and/or interacting in skills training group meetings are mentioned. A Standard DBT combines skills training with indi- client’s primary provider consults with the skills vidual therapy or intensive case management, plus trainers and takes such information into account in phone coaching by the individual provider and planning the individual treatment. weekly treatment team meetings. When DBT skills My emphasis on the importance of meetings be- training is offered without the individual provider tween individual therapists and skills trainers may component, some modifications in the conduct seem to contradict “consultation-to-the-­ patient” of skills training may be necessary. For example, strategies, which are also integral to DBT. First, I without an individual therapist, skills trainers may must point out that these consultation strategies do decide to provide phone, text, or e-mail coaching require DBT therapists to walk a very fine line. The between sessions. There may also be a greater em- issues are somewhat complex. When the therapeutic phasis on use of DBT smartphone coaching apps and unit is defined as a group of people, such as a DBT other DBT apps and websites. (To locate these, type team, a clinic, an inpatient unit, or some such en- “DBT self-help” in your search engine.) At times, tity where multiple therapists interact with and treat skills trainers may offer individual consultation ses- particular clients in a single coordinated treatment sions to group members. This may be particularly program, then consultation between therapists is es- necessary in groups for friends and family members, sential, provided that the clients are informed of and at times when group members are extremely dis- consent to such collaboration. Applying the consul- traught about a friend or relative and want and need tation strategies in these cases simply requires that more coaching in use of skills than can occur in a therapists refrain from intervening with each other single group session. 38 I. AN INTRODUCTION TO DBT SKILLS TRAINING Clarifying Individual Therapists’ versus cidality and/or severe disorders if the client’s indi- Skills Trainers’ Roles in Suicidal Crises vidual therapist agrees to the following: Standard DBT—including individual therapy, skills 1. The provider or a designated backup individ- training, as-­needed phone coaching/crisis interven- ual therapist must agree to resist the temptation to tion, and the DBT consultation team—was designed rely on the skills trainer to conduct interventions specifically for highly suicidal individuals with high aimed at reducing current suicidal and other se- emotion dysregulation. Reduction of suicidal and verely dysfunctional behaviors. This means that the other maladaptive behaviors is not the immediate individual therapist must agree to be available for goal of DBT skills training. Instead, skills training crisis calls from the skills trainer and/or the client is focused on teaching general skills that the clients during and following skills training sessions. This can apply to current problems in living. Application agreement is intended to ensure that the individu- of these skills to current suicidal behavior, to be- al therapist, rather than the skills trainer, makes haviors interfering with therapy progress (except on treatment decisions about the client when problems occasion behaviors interfering with skills training), or crises arise. In essence, a skills trainer calls the and to other severely dysfunctional behaviors is not individual therapist if a crisis arises, and then fol- necessarily attempted by skills trainers. lows treatment directions. This policy is based on In fact, as I discuss later, discussion of current the presumption that the individual therapist knows self-­ injurious behavior, substance use, and other the client much better than the skills trainer, and contagious behaviors is actively discouraged in skills that this knowledge is essential in making decisions training. Reports of suicidal ideation, prior self-­ about crisis management. The individual therapist injury, and other maladaptive behaviors/behaviors must be made aware of this policy, and must also be interfering with therapy—­including extreme prob- willing to be responsible for treatment management lems with skills training—are ordinarily relegated and decision making about treatment. Although a to individual therapists, primarily because of time skills trainer may make sure that a client actually constraints in conducting skills training. gets to the local hospital emergency department, Problems maintaining this skills training orien- this is very different from deciding that such a move tation arise when an individual therapist sends his should be made in the first place. An exception to or her clients to DBT skills training because of the this policy is made when a client is highly suicidal, strong data on DBT as an effective intervention for and the skills trainer believes medical treatment highly suicidal individuals. Our non-DBT therapist or emergency evaluation for inpatient treatment is colleagues know that therapists trained in DBT are needed, but the individual therapist either disagrees also trained in assessment and management of sui- without an adequate rationale or refuses to make cidal behavior. Thus a non-DBT therapist may start the necessary treatment management decision. In- mistakenly relying on a DBT skills trainer to man- dividual therapists should be advised also that skills age high-risk suicidal behavior, at least when the therapists are not available for crisis calls from their skills trainer is present or available by phone. Un- clients. fortunately, a skills training therapist in DBT is rely- 2. The individual therapist must agree to coach ing on an individual therapist in a similar manner. the client on use of DBT skills in everyday life. We In some cases a DBT skills trainer, if not trained in ordinarily give second copies of all the DBT skills DBT as a whole treatment, may not even be trained handouts and worksheets to our clients and ask them in management of suicidal behaviors. And therein to give these copies to their individual therapists. To lies the problem: Skills trainers teach skills. be successful, an individual psychotherapist needs to elicit from a client sufficient information about the skills taught in skills training to be able to help Managing Working with Clients the client apply the skills in troublesome areas. The of Non-DBT Individual Therapists therapist also needs to know (or learn) the skills and When a DBT skills client is in therapy (or case man- be able to apply the skills him- or herself; this is not agement) with a non-DBT therapist, it is particular- as simple as it might seem. It is important also to ly important for the skills trainer(s) to have a very advise therapists that skills trainers do not do tele- clear agreement with the individual therapist. In my phone coaching on skills, as that is viewed as the clinic, we only agree to accept a client with high sui- role for the individual therapist.  2. Planning to Conduct DBT Skills Training 39 3. Therapists must understand and agree that clarify who will be on call for the clients during and skills trainers will not give them reports about after skills training sessions. Thus we also ask each their client’s behaviors in group sessions or reports client’s primary therapist to fill out a crisis plan. A on group attendance. If a therapist wants such re- form for obtaining a crisis plan and other essential ports and a client agrees, a skills trainer may agree information from a primary therapist is shown in to give periodic reports to the client, who can then Figure 2.2. give such reports to the therapist. The principle here is contained within the consultation-to-the-­patient When Individual Psychotherapists strategy, which promotes the patient as a credible Do Not Incorporate Skills Coaching source of information who can intervene effectively into Psychotherapy on his or her own behalf within the health care net- work. (See Chapter 13 of the main DBT text.) Active intervention and skills coaching may not be compatible with the individual psychotherapy a par- In our clinic, we use the agreement in Figure 2.1 ticular therapist is willing to engage in. Some thera- and ask each non-DBT individual therapist to sign pists, for example, view helping clients learn new it. The experience in my clinic has been that most skillful behaviors as treating the “symptoms” in- individual therapists in private practice will agree to stead of the “illness.” In one setting, individual psy- these stipulations to get their clients into our skills chotherapists (who were physicians) told clients to groups. However, we have had some therapists who get coaching from the nurses in how to replace mal- initially agreed to these points but, when serious adaptive behaviors with skills. This sent the mes- crises arose, insisted that we make the clinical deci- sage that the new skills were not important, since sions about their clients. We have also had clients the “real therapy” was taking place with their indi- who were seeing therapists who refused to take af- vidual therapists. Clients with such therapists will ter-hours calls themselves, and instead used our area need extra help in using the skills they are learning. crisis line as their “backup therapist.” Unfortunate- Skills trainers can make a number of optional ly, many crisis clinics are staffed by volunteers with modifications to address these issues. They might little or no formal clinical training, and so a skills set up an extra weekly skills training meeting where trainer cannot usually turn client responsibility over clients can get help in figuring out how to use their to a crisis line volunteer. It is critical, therefore, that skills in troublesome life situations. But people skills trainers who do not want to take responsibil- often need help at the moment they are in crisis. ity for managing crises (particularly suicidal crises) Skills training is like teaching basketball: Coaches discuss crisis management with clients’ individual not only conduct practice sessions during the week, therapists before beginning skills training, and also but also attend the weekly game to help the players Client Name:                      Provider Name:                     Date (yyyy/mm/dd):            I am the primary individual  psychotherapist  case manager  pharmacotherapist for the client referred to above. I understand that my client will not be eligible to participate in the DBT Skills Training Program at                 unless he or she attends regular individual treatment sessions on an ongoing basis. As the primary provider for this client, I agree that I will: 1. Assume full clinical responsibility for my client. 2. Handle or provide backup services to manage client clinical emergencies. 3. Be available by phone or provide a backup provider phone number to call during skills training sessions of my client. 4. Provide and keep updated the Crisis Plan and Information from Primary Therapist form [Figure 2.2] attached. 5. Help my client apply DBT skills to his or her clinical problems. FIGURE 2.1. Primary individual provider agreement for clients in DBT skills training.  This must be completed with your client’s full awareness of all parties with whom this information may be shared. Please fill this form out on paper and have client return to the group leaders, or fill out digital copy at:                  and e-mail to one of the group leaders at: Group Leader’s Name:                      E-mail: Date (yyyy/mm/dd):            Client’s Name:                  Clinical ID:        DOB (yyyy/mm/dd): Your client’s group meets on:                         at: Primary Therapist: Name:               Phone (Office):        Phone (Cell):        Fax: E-mail:                        Available Hours: Address: If your client is at high suicide risk or in crisis requiring immediate intervention and you are unavailable, who should be called? Your Backup Therapist (when you are in town): Name:             Phone (Day):        Phone (Eve):        Phone (Cell): Address: Your Backup Therapist (when you are in town): Name:             Phone (Day):        Phone (Eve):        Phone (Cell): Address: Pharmacotherapist/Primary Care Physician/Nurse Practitioner (if applicable): Name:             Phone (Day):        Phone (Eve):        Phone (Cell): Case Manager (if applicable): Name:             Phone (Day):        Phone (Eve):        Phone (Cell): Significant Others (to call in an emergency): Name:                      Phone:           City: Name:                      Phone:           City: CRISIS PLAN How can you be reached during a crisis if disposition planning is needed? Who should be called for disposition planning if you are unavailable? (cont.) FIGURE 2.2. Crisis plan and information from primary therapist (confidential). 40  1. Brief history of client’s suicidal behavior. 2. Recent status of client’s suicidal behavior (last 3 months). Please describe the most recent and most severe self-injury/suicide attempt. Describe the form, date, circumstances and what intervention resulted, if any (e.g., ER, medical ward, ICU). 3. Crisis plan: Describe crisis plan you and client have agreed to for management of suicidal behavior. Describe the typical emotions, thoughts, and behaviors that may precede self-­injury/suicide attempts, and the strategies that a client has used successfully in the past. (EXAMPLE: My client states that if she gets angry or feels helpless, this causes emotion dysregulation. This then triggers the urge to hurt herself by burning herself. She states that if she has this urge, she has successfully coped with these by using these distraction strategies: calling her mother, playing with her dogs, going for a walk to the park, crocheting, having a bath, doing vigorous physical exercise, listening to loud music, or praying. As a last resort, she will call me or my backup therapist and discuss ways for her to get through the moment. When she calls, she says that she finds it really helpful when I help her to find a means of distraction, remind her that she has tolerated urges like this before, and help her try to solve the problem that may be leading to her feeling this way. This plan was developed with my client.) 4. If your client is assessed as in imminent risk of suicidal behavior, self-­injury, or violence, and neither you nor your backup can be immediately contacted, how should the skills trainers or other professional staff manage your client? 5. Describe any history of violence and use of weapons. Also specifically describe any occasions of violence and use of weapons in the last 3 months. Describe any current plans that you and the client have to deal with this behavior. 6. Describe any history of substance use. Also specifically describe substance misuse history in the last 3 months. Describe any current plans that you and the client have to deal with this behavior. 7. Client medications: Weight (lbs/kg)     Height (inches/cm)     Medications Dose For Medications Dose For                                                                                                       FIGURE 2.2 (cont.) 41 42 I. AN INTRODUCTION TO DBT SKILLS TRAINING use what they were practicing all week. With outpa- follows. First, carefully read the treatment notes for tients, this is usually best done via telephone calls. each of the skills to be used. What is important here In standard DBT, where clients have individual DBT is that providers know the skills and know what psychotherapists, phone calls to skills training ther- skills go with what problem or set of problems. apists are severely limited; almost all calls for help Second, decide whether to use a handout and/or are directed to the clients’ individual therapists. If worksheet in teaching the skill, or to teach it orally an individual therapist does not take calls or give without these materials. If you are planning on oc- coaching, however, a skills trainer may decide to ac- casionally using handouts and/or worksheets, copy cept them, at least when the reason for calling is to them and keep them handy in your office or nearby. get such coaching. When the occasion arises to teach a particular skill, On an inpatient unit, milieu staff members should discuss the idea of learning a new skill with the cli- learn the behavioral skills along with the clients. The ent. Use the orienting strategies discussed in Chap- staff members can then serve as coaches for the cli- ter 6 of this manual, if necessary, to sell the skill ents. One inpatient unit offers weekly skills consul- you want to teach. Giving a copy of the handout tation meetings. The meetings are run like academic to the client and keeping one yourself, review the office hours; clients can come at any time during of- skill using the skills training procedures described fice hours for coaching. Ideally, clients can also call in Chapter 6. Practice the skill with the client if pos- on one another for help. In another inpatient set- sible, and give an assignment or suggestion that the ting, one therapist teaches new skills; nursing staff client practice the skill before the next visit. As far as members conduct regular homework review groups, possible, be open to the client’s calling you between where clients meet together to go over their attempts sessions for skills coaching. Be sure to ask about the to practice new skills and get help with areas of diffi- client’s practice in the next visit. Periodically check culty; and individual therapists reinforce the clients’ in with the client to see whether he or she is still use of skills. In residential settings, it can be useful using the skills you have taught. Encourage contin- to offer advanced skills groups where group mem- ued skillful behavior. Although it may seem that bers help each other apply skills in daily situations. the directive quality of DBT skills training would Skills generalization can also be greatly enhanced be incompatible with psychoanalytic and supportive if individuals in a client’s environment—such as treatments, the fact that so many nonbehavioral and family members—also learn the skills and then help analytic therapists teach and/or integrate DBT skills with coaching the client every day.4 A skills trainer into their therapies suggests that this is not the case or individual therapist can then assist a family mem- (enter “psychoanalytic DBT skills” in your search ber in coaching the client. Adolescent skills training engine for examples). ordinarily includes both an adolescent and at least one parent, so each can coach the other. Parole of- References ficers can be taught the skills so they can coach the parolees on their caseloads. Primary care providers 1. Neacsiu, A. D., & Linehan, M. M. (2014). Border- can be taught skills so they can coach their patients. line personality disorder. In D. Barlow (Ed.), Clini- A skills curriculum has been developed for use in cal handbook of psychological disorders (5th ed., school settings, where teachers and school counsel- pp. 394–461). New York: Guilford Press. ors can coach students.4, 5 2. Sayrs, J. H. R., & Linehan, M. M. (in press). Devel- oping therapeutic treatment teams: The DBT model. New York: Guilford Press. Integrating Skills Training into Non-DBT 3. Case Management Society of America. (n.d.). Individual Therapy Retrieved from www.cmsa.org/Home/CMSA/­ WhatisaCaseManager/tabid/224/Default.aspx Many non-DBT psychotherapists, counselors, case 4. Miller, A. L., Rathus, J. H., & Linehan, M. M. managers, pharmacotherapists, other mental health (2007). Dialectical behavior therapy with suicidal providers, nurses, doctors, and other profession- adolescents. New York: Guilford Press. als in general medical practice will find it useful at 5. Mazza, J. J., Dexter-Mazza, E. T., Murphy, H. E., times to integrate DBT skills into their treatment of Miller, A. L., & Rathus, J. H. (in press). Dialecti- clients. Providers may want to use only one skill or a cal behavior therapy in schools. New York: Guilford variety of skills across different modules. Strategies Press. for incorporating skills into ongoing therapy are as