Skills Training Orientation PDF

3. Structuring Skills Training Sessions 47 TABLE 3.3 (cont.) Measures for adults (cont.) State–Trait Anger Expression Inventory (STAXI) Biometrics Research Department, New York State Spielberger, C. D., Jacobs, G...

3. Structuring Skills Training Sessions 47 TABLE 3.3 (cont.) Measures for adults (cont.) State–Trait Anger Expression Inventory (STAXI) Biometrics Research Department, New York State Spielberger, C. D., Jacobs, G. A., Russell, S., Psychiatric Institute. & Crane, R. S. (1983). Assessment of anger: The Contact American Psychiatric Press, Inc., 800-368- State–Trait Anger Scale. Advances in Personality 5777, www.appi.org/index.html Assessment, 2(2), 1–47. Contact Psychological Assessment Resources, 800- UCLA Loneliness Scale 331-8378, www4.parinc.com Russell, D., Peplau, L. A.. & Ferguson, M. L. (1978). Developing a measure of loneliness. Journal of Structured Clinical Interview for DSM-IV, Axis I (SCID) Personality Assessment, 42, 290–294. First, M. B., Spitzer, R. L., Gibbon, M., & www.fetzer.org/sites/default/files/images/stories/ Williams, J. B. W. (1995). Structured Clinical pdf/selfmeasures/Self_Measures_for_Loneliness_and_ Interview for Axis I DSM-IV Disorders—­Patient Interpersonal_Problems_UCLA_LONELINESS.pdf Edition (SCID-I/P). New York: Biometrics Research Department, New York State Psychiatric Institute. University of Washington Risk Assessment Protocol Contact Biometrics Research for a research version (UWRAP)a of the SCID, 212-960-5524 Reynolds, S. K., Lindenboim, N., Comtois, K. A., Murray, A., & Linehan, M. M. (2006). Risky Structured Clinical Interview for DSM-IV, Axis II assessments: Participant suicidality and distress Personality Disorders (SCID-II) associated with research assessments in a treatment First, M. B., Gibbon, M., Spitzer, R. L., Williams, study of suicidal behavior. Suicide and Life-­ J. B. W., & Benjamin, L. (1996). User’s guide for Threatening Behavior, 36(1), 19–33. the Structured Clinical Interview for DSM-IV Axis http://blogs.uw.edu/brtc/publications-­assessment-­ II Personality Disorders (SCID-II). New York: instruments Measures for adolescents Brief Reasons for Living Inventory for Adolescents Suicidal Behaviors Interview (SBI) (BRFL-A) Reynolds, W. M. (1990). Development of a semi-­ Osman, A., Kopper, B. A., Barrios, F. X., Osman, structured clinical interview for suicidal behaviors in J. R., Besett, T., & Linehan, M. M. (1996). The adolescents. Psychological Assessment, 2(4), 382–390. Brief Reasons for Living Inventory for Adolescents Contact: [email protected] (BRFL-A). Journal of Abnormal Child Psychology, 24(4), 433–443. Suicide Ideation Questionnaire—­Junior https://depts.washington.edu/brtc/files/Osman,%20 Siemen, J. R., Warrington, C. A., & Mangano, A.%20(1996)%20The%20Brief%20RFL%20for%20 E. L. (1994). Comparison of the Millon Adolescent Adolescents%20(BRFL-A).pdf Personality Inventory and the Suicide Ideation Questionnaire—­Junior with an adolescent inpatient Schedule for Affective Disorders and Schizophrenia for sample. Psychological Reports, 75(2), 947–950. School-Age Children (Kiddie-SADS) Contact Psychological Assessment Resources, 800- Endicott, J., & Spitzer, R. L. (1978). A diagnostic 331-8378, www4.parinc.com interview: The Schedule for Affective Disorders and Schizophrenia. Archives of General Psychiatry, 35(7), 873–844. www.wpic.pitt.edu/ksads Note. I use the DSM-IV to assess for borderline personality disorder but am moving to DSM-V to measure other disorders. Orienting the Client to the Specifics thoroughly covered at intake or by the individual of Skills Training therapist in standard DBT, the pretreatment meet- ing with the skills leader or co-­leader can be much Following assessment, the therapist should briefly briefer. In my clinic, each individual in our standard present the skills deficit model of emotional and be- DBT program first has a thorough intake (including havioral dysregulation, which is discussed briefly in diagnostic interviews), and then meets with the in- Chapter 1 of this manual and in detail in Chapter dividual DBT therapist for a thorough discussion of 2 of the main DBT text. If diagnostic interview- DBT skills training. Clients then meet with the skills ing and commitment to skills training have been leader or co-­leader for 15 or so minutes before their 48 I. AN INTRODUCTION TO DBT SKILLS TRAINING first skills session. Individuals in our skills training Developing a Collaborative groups (with no individual therapy) have an intake Commitment to Do Skills Training session first and then meet with the skills leader or Once you have decided to accept a person into skills co-­leader to evaluate whether skills training is ap- training, it is important that you yourself make a propriate for each client’s goals. Initial commitment commitment to treating the individual. Entering a for skills training is obtained at this meeting. treatment with reluctance, reserve, or antagonism, The individual pretreatment interview with the or on unwanted commands from others, can mark- skills trainer should orient the client to the specif- edly impair your chances of developing a strong and ics of skills training. This includes how the group collaborative relationship with your skills train- (if there is a group) will function, what the client’s ing participants. It is also important to talk with and the trainer’s roles in skills training are, and how potential clients about any pressures from family skills training is different from other types of therapy members that may be the main impetus for their In standard DBT (which includes an individual coming to DBT or to skills training specifically—­ provider), these discussions ordinarily take place particularly with adolescents coming to treatment between a client and an intake coordinator (if there with their parents. Because standard DBT requires is one), and then between the client and the indi- both individual therapy and skills training, it is al- vidual provider. In standard DBT, the skills trainer together possible that an individual therapist is also usually calls and then meets new clients for 5–15 pressuring a client to attend skills training. For minutes before their first skills training session. If DBT to be effective, individuals must participate skills training is a stand-alone intervention or if voluntarily; thus, you may need to work with the skills are being integrated into ongoing individual potential clients to see the pros and not just the cons therapy, then the skills trainer performs all the tasks of coming to skills training and learning the DBT that an individual provider would normally provide. skills offered. Remember, participation can be pres- sured and voluntary at the same time. At this point, Orienting Clients to Skills Training if you accept a reluctant but mostly willing client versus Other Types of Therapy for treatment, the practice of radical acceptance and opposite action will be particularly important. It is essential that the leaders discuss the difference Working with your DBT team will also be impor- between a skills training group and other group or tant for strengthening your personal commitment to individual psychotherapies. Many individuals look the task. Follow all of the DBT guidelines on obtain- forward to a group where they can share with indi- ing an initial therapy commitment from skills train- viduals like themselves. Although there is much shar- ing participants. These are outlined and discussed ing in the group, it is not unlimited—and it is focused in Chapters 9 and 14 of the main DBT text. It is on practicing skills, not on whatever crises may have impossible to get too much commitment! A skills occurred during the week. Many participants have trainer should not assume that other therapists (e.g., never been in any kind of behavior therapy, much the individual psychotherapist or the intake inter- less a skills-­oriented group. My experience is that viewer in a clinic setting) have gotten the commit- the difference cannot be stressed too much. Often ment needed. This is a mistake my colleagues and clients have had an enormous amount of nonbehav- I made early in our program, and we paid a dear ioral therapy in which they have been taught various price for it. The pretreatment session is also a good “necessary ingredients” for therapeutic change—­ opportunity to begin developing a personal thera- ingredients that skills training often does not address peutic alliance with the client (the fifth pretreatment extensively. In every group we have conducted so far, task; see Chapters 14 and 15 of the main DBT text one or more clients have gotten angry about their in- for more on this topic). ability to talk about “what is really important” in the group. For one client, talking about whatever comes to mind was so firmly associated with the process of Beginning to Develop the Alliance therapy that she refused to acknowledge that skills training could be a form of therapy. Needless to say, Use of standard DBT therapeutic relationship strate- there was much friction with her in the group. I dis- gies, such as relationship acceptance and relation- cuss orienting to skills training in more detail in this ship enhancement, is particularly important at the manual’s Chapters 4 and 6. start of skills training (see below). In a group con-  3. Structuring Skills Training Sessions 49 text, one of the first tasks of the group leaders is to ing the relationship between the characteristics of enhance the bonding between group clients and the disordered emotion regulation and the goals of skills leaders, and to begin the process of building group training is distributed and discussed (see Chapter 6 cohesion. We have found it useful to have the lead- of this manual for details); usually I also write this ers call each new group member a few days before on the whiteboard in the therapy room. the first skills training meeting to remind him or her It is essential here for the skills trainer to com- of the session, clarify directions, and communicate municate an expectancy that the treatment will be looking forward to meeting him or her. It is also effective at helping the clients improve the quality a good time for the leaders to address last-­minute of their own lives. The treatment must be “mar- fears and plans to drop out before even starting. In- keted” to clients. (See Chapters 9 and 14 of the dividuals joining an ongoing group are also invited main DBT text for further discussion of market- to come early to their first session for a brief orien- ing therapy to clients and eliciting commitments.) tation to the basics of DBT skills training. At the At this time I usually make the point that DBT is session before new members join, we usually discuss not a suicide prevention program (or substance ab- the importance of encouraging and welcoming new stinence or symptom improvement program), but members. Clients starting a module late are, in ad- a life enhancement program. It is not our idea to dition, given a brief review of skills already taught. get people to live lives not worth living, but rather The leaders should arrive a few minutes early be- to help them build lives they actually want to live. fore each group meeting, especially the first meeting Dialectical and validation strategies (see Chapters of a new group, to greet clients and interact briefly 8 and 9 of the main DBT text, and Interpersonal with group members. For reluctant and/or fearful Effectiveness Handouts 15–19a) are the primary clients, this can be a soothing experience. It also of- treatment vehicles here. fers an opportunity for leaders to hear concerns and refute plans to leave early. We try to confine indi- Relationship Acceptance vidual interactions to the context of group mingling, in order to keep the essential identity of group rather Relationship acceptance strategies in group skills than individual therapy. This issue is discussed fur- training require that leaders experience and commu- ther below. nicate acceptance of group members in several dif- As might be expected, group members are very ferent spheres. First, the clinical progress of each cli- timid and fearful during the first meeting. Appro- ent must be accepted as it is. Relationships between priate behavior is not clear, and the trustworthiness leaders and group members, between members and of group clients is doubtful. We generally begin by other therapists, between and among individual going around the group and asking each person to members, between the group leaders themselves, give his or her name, to say how he or she heard and between the group as a whole and the group about the group, and to give any information about leaders must also be accepted. The sheer complex- him- or herself the person cares to share. The group ity of the situation can make acceptance difficult, leaders also give information about themselves and because it is easy to get overwhelmed; rigidity and how they came to be leading the group. nonacceptance usually follow. It is essential to try The next task of skills trainers is to help clients not to pave over or quickly truncate conflict and dif- see the relevance of a skills training model to their ficult emotions in the group. Many clients who have own lives. An overview of the skills training treat- trouble regulating their emotions also have great ment year is given (see Table 2.2 in Chapter 2); a difficulty with group skills training. Some are in theory of disordered emotion regulation that stress- it only because it is required, and they feel uncom- es the role of inadequate skills is presented; and the fortable and are unable to interact effectively in this format for the upcoming sessions is described. If the atmosphere. For others, skills seem unimportant, group is homogeneous with regard to disorder or juvenile, or silly. Still others quickly become demor- problem type (e.g., substance use disorders, suicidal alized by unsuccessful attempts to master the skills. behavior, eating disorders), then a similar skills defi- Group skills training with clients who have dif- cit model of the specific problem behavior is also ficulties regulating their emotions does not have the provided. Discussion is elicited at each point about naturally occurring reinforcement for leaders that the relevance of the material to the client’s own ex- most groups have. Skills training leaders are faced periences. A handout (General Handout 1) illustrat- with dead silences; noncompliance; inappropriate 50 I. AN INTRODUCTION TO DBT SKILLS TRAINING and sometimes extreme responses to the slightest probably be helpful to the group members. This is deviation from perfect sensitivity; and a group at- no easy task. The task is made even more difficult by mosphere that at times can be uncommunicative, the fact that group members often share with one an- hostile, unsupportive, and unappreciative. The po- other their previous failures in individual and other tential for mistakes in leading such a group is vast. A group therapies, and comment about the hopeless- leader can expect not only to make many mistakes, ness of their situations and the meagerness of any but also to be acutely aware of the many mistakes help that can be offered. Group members often por- the other group leader makes. Reality acceptance tray their problems as Goliath and the treatment as skills are crucial if mistakes are to be responded to David, but without David’s Old Testament success. in a nondestructive manner. The task of the leaders is to convey the story as it Leaders’ attacking group members or threaten- indeed occurred. ing them is almost always a result of a failure in Expertise, credibility, and efficacy can be con- relationship acceptance. Acceptance requires a non- veyed in a variety of ways. Skills trainers’ neatness, judgmental attitude that sees all problems as part of professionalism, interest, comfort, self-­confidence, the therapeutic process—“grist for the mill,” so to speech style, and preparation for therapy sessions speak. Leaders simply have to see that most prob- are no less useful in skills training than in indi- lematic responses on the part of the group derive vidual psychotherapy. It is especially important in from emotionally dysregulated response patterns. In conducting groups to have the group room prepared other words, if clients didn’t present with the prob- before the group members arrive: Handouts and lems that drive leaders crazy, they wouldn’t need a worksheets should be distributed; chairs should be skills training group. To the extent that leaders fail in place; and the refreshments should be made and to recognize this fact, they are likely to engage in available (if refreshments are provided). The key to rejecting, victim-­bashing behaviors that may be too the credibility problem, in my experience, is that subtle to be seen for what they are, but nonetheless many clients—­ particularly those with severe and have an iatrogenic effect. In other words, an “easy” chronic disorders—simply do not believe that learn- leader disposition has to be either innate or culti- ing the skills presented will in fact be helpful. This vated. disbelief detracts from any positive motivation to learn the skills, and unless clients learn the skills and obtain positive rewards, it is difficult to change Relationship Enhancement this attitude. Indeed, this dynamic can become a vi- Relationship enhancement strategies involve behav- cious circle. iors by skills trainers that increase the therapeutic Leaders must come up with a way to break this values of the relationship. In other words, they are vicious circle if the clients are to move forward. The behaviors that make the relationship more than sim- most helpful approach is for the leaders to tell group ply a helpful friendship. A positive, collaborative members that in their experience, these skills have interpersonal relationship is no less important in been helpful to some people some of the time. This, skills training than it is in any other type of therapy. of course, can only be said if it is indeed the lead- However, the development of such a relationship is ers’ experience; leaders who have never taught these considerably more complex in group skills train- skills must rely on others’ experience. (Our outcome ing, because of the increased number of individu- data can form a database for inexperienced skills als involved in the relationship. The question for the trainers.) In addition, leaders can share their own group leaders is how to establish such a relation- experience with skills. For some clients, the most ship between group members and leaders, as well as powerful inducement to learn the skills is the knowl- among the members themselves. edge that the leaders have found the skills helpful for All of the DBT strategies are designed in one way themselves. or another to enhance the collaborative working re- Credibility is damaged when leaders promise that lationship. The strategies discussed here are those a particular skill will solve a particular problem. intended primarily to establish the group leaders In fact, DBT is something of a shotgun approach: as experts, as creditable, and as efficacious. Thus Some of the skills work some of the time for some the goal of these strategies is to communicate to the of the people. I have not had any clients to date who group members that the leaders indeed know what could not benefit from something, but no one ben- they are doing and have something to offer that will efits from everything. It is crucial to present this in-  3. Structuring Skills Training Sessions 51 formation; otherwise, the leaders’ credibility is on same set of skills or to convey expertise in the same the line immediately. areas. The dialectical perspective as a whole is what Another key issue to address is that of trust and counts. confidentiality. Opportunities to display trustwor- thiness occur when one member is absent from a Presenting Skills Training Guidelines group session. At all times, confidences must be kept, and unnecessary information about a group Make the rules of skills training explicit at the very member should not be conveyed when that group beginning. Their presentation is an important part member is absent. The absence of a group mem- of the treatment process, not a precursor to the pro- ber, however, can serve as a powerful opportunity cess and it offers an opportunity for the skills train- for enhancing other group members’ trust in the ers to specify and obtain agreement to the treatment leaders. The manner in which the absent member contract from each client. My experience is that is discussed conveys information to all other mem- the presentation and discussion of rules can usu- bers about how they will be treated when they are ally be accomplished at the beginning of each itera- absent. Generally, the policy should be to protect tion of the mindfulness module. In an open group, group members from negative judgments. For ex- the guidelines should be discussed each time a new ample, if a group member blows up, walks out of a member enters the group. Guidelines I have found session, and slams the door, the leaders can respond useful are outlined in General Handout 3 and de- to the event with sympathetic explanations rather scribed below. than with critical judgments. This same strategy, of course, can be used when 1. Participants who drop out of skills training all group members are present. It is not unusual are NOT out of skills training. Only clients who for one group member to behave in a fashion that miss 4 weeks of scheduled skills training sessions in the leaders know will result in negative judgments a row have dropped out of therapy and cannot re- by other group members. Or other group members enter for the duration of the time in their treatment may be quite critical of one another. The leaders’ contract. For example, if a client has contracted for role here is that of protectors of the accused and the 1 year, but misses 4 weeks in a row during the sixth judged. This leadership task cannot be overempha- month, then he or she is out for the next 6 months or sized, especially during the clients’ first modules in so. At the end of the contracted time, he or she can skills training. Not only does this approach serve to negotiate with the skills trainer(s) (and the group, if model nonjudgmental observation and description he or she was in one and it is continuing) about re- of problematic behavior for group members; but it admission. There are no exceptions to this rule. The also conveys to all of the members that when they rule for skills training is thus the same as the rule for are attacked, they too will be protected. The most individual DBT psychotherapy. useful way to convey expertness and credibility is, Across multiple studies using this rule, our drop- of course, to be helpful. Thus the leaders need to out rates in 1-year DBT programs have been rea- think through skills that have a high likelihood of sonably low. I suspect that our emphasis on a time-­ working with a particular group member. A skill limited commitment and the clarity of the rules that is working should be highlighted so that the about how to drop out are crucial to our low drop- member will also see the benefits. out rate. Skills trainer credibility in standard DBT group 2. Participants who join the skills training group skills training is further complicated by the fact support each other. There are many ways to be a that there are two group leaders. In my clinic, the supportive person in skills training sessions. It is im- co-­leader is usually a trainee who, in fact, does not portant that skills leaders review what is needed to have the expertise of the primary leader. It is es- be supportive. This includes preserving confidenti- sential that the primary leader not undermine the ality, attending regularly, practicing skills between credibility and expertness of the co-­leader. It is im- sessions, validating others, giving noncritical feed- portant for the inexperienced co-­leader to find his back, and being willing to accept help from a per- or her emotional center and act from there. It is this son (a leader or a fellow client) from whom help is inner-­centeredness, rather than any particular set of requested. therapeutic skills, that is most important. The pri- A good group norm of coming on time and prac- mary leader and co-­leader do not need to have the ticing skills between sessions is essential—but ad- 52 I. AN INTRODUCTION TO DBT SKILLS TRAINING mittedly hard at times to develop. Discussing the im- of the strengths of group DBT. The model here is portance of building norms at the start of each new similar to that of Alcoholics Anonymous and other module can be very helpful. My experience is that self-help groups, where calling one another between most skills training members want such norms to meetings, socializing, and offering mutual support develop. (We have found it very effective to give out are viewed as therapeutic. Encouragement of such stickers to each person who comes to skills training relationships, however, provides the possibility for on time that week.) interpersonal conflict that is inherent in any rela- 3. Participants who are going to be late or miss tionship. The key is whether interpersonal problems a session call ahead of time. that arise outside the sessions can be discussed in This rule serves several purposes. First, it is a the sessions (or, if that is too difficult or threatens to courtesy to let skills trainers know not to wait for get out of hand, with the leaders). To the extent that latecomers before starting. Second, it introduces an such issues can be discussed and appropriate skills added response cost for being late and communi- can be applied, a relationship can be advantageous. cates to clients that promptness is desirable. Finally, Troubles arise when a relationship cannot be dis- it gives information as to why a client is not present. cussed and problems increase to such an extent that 4. Participants do not tempt others to engage one member finds it difficult or impossible to attend in problem behaviors. This rule asks clients not to meetings, either physically or emotionally. come to skills sessions under the influence of drugs Group leaders should assign current sexual part- or alcohol. However, if drugs or alcohol have al- ners to different groups at the onset. This rule also ready been used, clients are to come to the sessions functions to alert group members that if they enter acting clean and sober. Particularly for those with into a sexual relationship, one member of the pair substance use disorders, a rule saying not to come will have to drop out. To date we have had several to skills sessions when using substances just gives sexual relationships begin among group members; individuals with poor self-­regulation a good excuse each created enormous difficulties for the partners for not coming. Instead, my position is that skills involved. In one case, the initiating partner broke learning is context-­dependent, and thus for persons off the relationship against the wishes of the other, with substance use disorders, learning and practic- making it very hard for the rejected partner to come ing skills while under the influence of drugs or alco- to group sessions. Generally, this rule is clear to ev- hol are particularly important. This is definitely the eryone involved. Without the rule, however, deal- time when skills are needed. ing with an emerging sexual relationship between This rule also outlaws descriptions of dysfunc- clients is very tricky, since post hoc application of tional behaviors, which can be contagious. In my rules is unworkable with individuals who have dys- experience, communications about self-­injury, sub- regulated emotions. stance use, bingeing or purging, and similar behav- There are two exceptions to the rule. In skills iors elicit strong imitation effects among individuals training groups for friends and families, where cou- with disordered emotion regulation. These urges to ples, partners, and multiple family members often imitate can be very difficult to resist. Therefore, just join the group, it is not reasonable or feasible to out- as in individual DBT, clients in skills training must law private relationships. A similar situation arises agree not to call or communicate with one another in the multifamily skills groups commonly held after a self-­injurious act. At every point in DBT, a with adolescents. In these situations, however, it is major objective is to diminish the opportunity for important to note that when relationship conflicts reinforcement of dysfunctional behaviors. This is threaten the group, the leaders will approach it in a particularly true for discussions of suicidal behav- manner similar to that described above. iors. 6. Participants who are suicidal and/or have se- 5. Participants do not form confidential rela- vere disorders must be in ongoing individual treat- tionships outside of skills training sessions. The ment. This rule is ordinarily discussed with clients key word in the fifth rule is “confidential.” Clients during pretreatment (rather than during a group ses- may not form relationships outside the sessions that sion), and the requirement to be in individual treat- they cannot discuss in the sessions. DBT encour- ment is laid out at that time. Of note here is that ages outside-of-­session relationships among group these clients must actually meet with their individu- clients. In fact, the support that members can give al therapists on a regular basis to stay in skills train- one another with daily problems in living is one ing. If the clients are in individual DBT treatment,  3. Structuring Skills Training Sessions 53 then they cannot miss four scheduled individual ses- 1. People are doing the best they can. The idea sions in a row. If they are in another form of individ- here is that all people at any given point in time are ual therapy, then the attendance guidelines of that doing the best they can, given the causes of behavior treatment must be followed. The exception to this that have occurred up to this moment. rule is when clients are on a waiting list for therapy. 2. People want to improve. The common char- Data collected by a Canadian research team found acteristic of all people is that they want to improve that skills training alone was effective in reducing their lives. As noted by the Dalai Lama at a meeting suicide attempts in suicidal individuals on a treat- I was part of, a common characteristic of all people ment waiting list.3 is that they want to be happy. This early emphasis on the likely need of highly 3. *People need to do better, try harder, and be dysregulated and/or suicidal participants for extra more motivated to change. The fact that someone is help in mastering the skills is very important later doing the best he or she can and wants to do even when the clients run into difficulty. It is all too easy better does not mean that this is enough to solve the for the skills trainers to overestimate the ease of problem. (The asterisk here means that this is not learning skills; such overestimation sets the clients always true. In particular, when progress is steady up for later disillusionment and hopelessness. and is occurring at a realistic rate, with no let-up or DBT skills training does not require that the in- episodic drop in effort, doing better, trying harder, dividual therapist be a DBT therapist. Nonetheless, and being more motivated are not needed.) the requirement for individual therapy can still be 4. *People may not have caused all of their own quite formidable at times. In our experience, it is problems, but they have to solve them anyway. Peo- not uncommon for individual therapists in the com- ple have to change their own behavioral responses munity to get pushed past their limits by clients and alter their environment for their lives to change. with dysregulated emotions, and then to terminate (The asterisk here indicates that with children or therapy precipitously with these clients. When this disabled persons, others might be needed to solve happens, it can be extraordinarily difficult to find some problems. For example, young children can- an individual therapist willing to work with such not get themselves to treatment if parents or others clients, especially with those who are mourning the refuse to take them.) loss of previous therapists. This is especially prob- 5. New behavior has to be learned in all relevant lematic when the clients cannot afford to pay the contexts. New behavioral skills have to be practiced high fees often charged by professionals who are in the situations where the skills are needed, not just experienced enough to be helpful. Unfortunately, in the situation where the skills are first learned. many public health clinics are so understaffed that 6. All behaviors (actions, thoughts, emotions) they cannot provide individual psychotherapy, or are caused. There is always a cause or set of causes clients may have already burned out their local clin- for actions, thoughts, and emotions, even if people ics. In these cases, the skills training leaders often do not know what the causes are. must function as short-term backup crisis therapists 7. Figuring out and changing the causes of be- and assist the clients in finding appropriate individ- havior is a more effective way to change than judg- ual therapists. ing and blaming. Judging and blaming are easier, but anyone who wants to create change in the world has to change the chains of events that cause un- Presenting DBT Assumptions wanted behaviors and events. The assumptions underlying treatment are outlined in General Handout 4 and described below. Along with the skills training guidelines, they are present- Format and Organization ed and discussed with skills participants during ori- of Ongoing Skills Training Sessions entation (which is repeated before the start of each Mindfulness skills module) and in person with cli- The structuring of session time is the major factor ents who join a skills group after the first session of differentiating formal DBT skills training from DBT a module. An “assumption” is a belief that cannot individual psychotherapy. In individual DBT psy- be proved, but group members agree to abide by it chotherapy, the agenda is set by a client’s behavior anyway. DBT across the board is based on the fol- since the last session and within the current session; lowing assumptions. the agenda is open until the client shows up for the