Skills Training Procedures PDF

4. Skills Training Treatment Targets and Procedures 65 Priority 3: ing sessions. Skills trainers matter-of-­factly suggest Reducing Therapy-­Interfering Behaviors their use when appropriate. The key point here is...

4. Skills Training Treatment Targets and Procedures 65 Priority 3: ing sessions. Skills trainers matter-of-­factly suggest Reducing Therapy-­Interfering Behaviors their use when appropriate. The key point here is that if skills trainers allow skills training sessions Behaviors that interfere with therapy, but do not de- to become focused on the therapy process or on cli- stroy it, are not ordinarily addressed systematically ents’ life crises—­including suicidal behaviors and in skills training. This decision is based primarily on quality-of-life-­interfering behaviors—then training the fact that if therapy-­interfering behaviors were a in skills will be forfeited. high-­priority treatment target for individuals with As I have discussed in Chapter 3 of this manu- high emotion dysregulation, trainers might never al, there is a wind-down period at the end of each get around to the designated skills training. Skills skills training session. This is an appropriate time training does not address the therapy process itself, to observe therapy-­ interfering behaviors or, even except as an avenue for teaching and practicing the more importantly, improvement in previous inter- skills being taught. When therapy-­ interfering be- fering behaviors. As long as everyone gets a chance haviors are occurring, effective strategies are (1) to to voice an observation, this time can be used as ignore the behavior, if it is brief; or (2) in a matter- therapy process time. One of the advantages of an of-fact but firm tone, ask the client to stop the be- observing wind-down is that it provides a time and havior and then resolutely focus (no matter what) place for discussing behaviors that are interfering on teaching the skills in the module at hand. This with therapy. (Cautions about process-­ observing is almost always the strategy employed with the less wind-downs have also been discussed in Chapter 3.) serious therapy-­ interfering behaviors. Sometimes these behaviors offer a particularly good opportu- nity for practicing the skills currently being taught. Skills Training Procedures: At most, these behaviors are commented on in a way How to Meet Skills Training Targets that communicates the desirability of change, while at the same time letting the client know that very lit- During skills training, and more generally through- tle time can be devoted to problems unrelated to the out DBT, skills trainers and clients’ individual treat- skills being taught. Thus mood-­dependent passivity, ment providers must insist at every opportunity that restlessness, pacing around the room, doodling, sit- clients actively engage in the acquisition and prac- ting in odd positions, attempts to discuss the week’s tice of skills needed to cope with life as it is. In other crisis, oversensitivity to criticism, or anger at other words, they must directly, forcefully, and repeatedly clients will be ignored at times. The client is treated challenge the passive problem-­solving style of indi- (ingeniously, at times) as if he or she is not engaging viduals with emotion dysregulation. The procedures in the dysfunctional behaviors. described below are applied by every DBT provider At other times, a skills trainer may instruct or across all modes of treatment where appropriate. urge such a client to try to apply behavioral skills to They are applied in a formal way in the structured the problem at hand. For example, a client who gets skills training modules. angry and threatens to leave may be instructed to try There are three types of skills training proce- to practice distress tolerance skills or the emotion dures. Each type focuses on one of the Priority 2 tar- regulation skill of opposite action (i.e., acting oppo- get behaviors: (1) skill acquisition (e.g., instructions, site to the action urge of anger). A client who is re- modeling); (2) skill strengthening (e.g., behavioral fusing to participate may be asked whether he or she rehearsal, feedback); and (3) skill generalization is being willful. If the response is “yes,” the trainer (e.g., homework assignments and homework review, may ask whether the client is willing to practice the discussion of similarities and differences in situa- skill of willingness. I often ask, “Any idea of when tions). In skill acquisition, a trainer is teaching new you will be willing to practice willingness?” A client behaviors. In skill strengthening and generalization, who is withdrawn and dissociating may be urged the trainer is trying both to fine-tune skilled behav- to practice crisis survival skills (e.g., cold gel pack iors and to increase the probability that the person across the eyes, paced breathing). In our groups, we will use the skilled behaviors already in his or her keep a number of rubber balls with spikes, a balance repertoire in relevant situations. Skill strengthening board, and cold gel packs available for use by people and skill generalization, in turn, require the appli- who are in danger of dissociating during skills train- cation of contingency procedures, exposure, and/or 66 I. AN INTRODUCTION TO DBT SKILLS TRAINING cognitive modification. That is, once the trainer is Some clients have skill deficits and are fearful sure that a particular response pattern is within the about acquiring the new skills. It can be useful to client’s current repertoire, then other procedures are point out here that learning a new skill does not applied to increase the client’s effective behaviors mean actually having to use the skill. That is, a per- in everyday life. It is this emphasis on active, self-­ son can acquire a skill and then choose in each situ- conscious teaching, typical of many approaches to ation whether to use it or not. Sometimes clients do CBT, that differentiates DBT from many psychody- not want to learn new skills because they feel hope- namic approaches to treating clients with disordered less that anything will really help. I find it useful to emotion regulation. Some skills training procedures, point out that every skill I teach has helped either however, are virtually identical to those used in sup- me or people I know. However, a skills trainer can- portive psychotherapy. The targets of skills training not prove ahead of time that particular skills will are determined by the parameters of DBT; the em- actually help a given individual. Thus I also point phasis on certain skills over others is determined by out that no skill is likely to be useful to every per- behavioral analysis in each individual case. son. Before teaching any new skill, the trainer should give an overall rationale (or draw it in Socratic fash- Skill Acquisition ion from the client) for why the particular skill or The second half of each skills training session is pri- set of skills might be useful. At times, this may only marily focused on teaching new material, generally require a comment or two; at other times, it may re- through lectures, discussions, practice, and role- quire extensive discussion. At some point, the skills plays. Each skills training module contains a num- trainer should also explain the rationale for his or ber of specific behavioral skills. One or sometimes her methods of teaching—that is, a rationale for the two skills are taught in each session, or three if some DBT skills training procedures. The most impor- of the skills are very easy to learn. Although it is tant point to make here, and to repeat as often as usually not a good idea to present a lot of individual needed, is that learning new skills requires practice, skills to be learned (the idea being that it is better to practice, practice. Equally important is that practice learn a few skills well than a lot of skills poorly), I has to occur in situations where the skills are need- have found that presenting many skills counteracts ed. If these points do not get through to a client, two problems with individuals who have difficulties there is not much hope that he or she will actually regulating their emotions. First, presenting many learn anything new. Once oriented, the client needs skills suggests that the trainer is not oversimplifying to make a recommitment to learning each skill and the problems to be solved. Second, teaching a large each skill module, as well as a commitment every quantity of skills works against clients’ being able week to practice new skills between sessions. to say credibly that absolutely nothing works. If one thing doesn’t work, the trainer can always suggest Assessing Clients’ Abilities trying a different skill. With many skills to draw from, the client’s resistance usually runs out before Skill acquisition procedures are aimed at remedi- the trainer’s ability to offer new skills to try does. ating skill deficits. DBT does not assume that all, or even most, of the problems that a person with emotion dysregulation has are motivational in na- Orienting and Committing to Skills Training: ture. Instead, the emphasis is on assessing the ex- Task Overview tent of the person’s abilities in a particular area; Skills acquisition begins with orienting and commit- skill acquisition procedures are then used if skill ment strategies. Orienting is a skills trainer’s chief deficits exist. It can, however, be very difficult to means of selling the new behaviors as worth learn- determine whether clients with high emotion dys- ing and likely to work. Skills training can only be regulation are incapable of doing something, or are accomplished if a person actively collaborates with capable but emotionally inhibited or constrained by the treatment program. In addition, knowing exact- environmental factors. Although this is a complex ly what the task is, what one’s role is, and what one assessment question with any client population, it can expect from the other person facilitates learn- can be particularly hard with these individuals be- ing enormously. Orientation is called for with each cause of their inability to analyze their own behav- specific skill and with each homework assignment. ior and abilities. For example, they often confuse  4. Skills Training Treatment Targets and Procedures 67 being afraid of doing something with not being able of the procedures also affect other factors related to to do it. In addition, there are often powerful con- skilled behavior. For example, they may work be- tingencies mitigating against their admitting having cause they give the individual “permission” to be- any behavioral capabilities. (I have reviewed many have in a certain way, and thus reduce inhibitions, of these in Chapter 10 of the main DBT text.) Cli- rather than because they add to the individual’s be- ents may say that they do not know how they feel havioral repertoire. The principal skill acquisition or what they think, or that they can’t find words, procedures are instructions and modeling. when in reality they are afraid or too ashamed to express their thoughts and feelings. As many of Instructions them say, they often do not want to be vulnerable. Some clients have been taught by their families and In DBT, “instructions” are verbal descriptions of the therapists to view all of their problems as motiva- skill components to be learned. This direct teach- tionally based, and have either bought that story ing constitutes didactic strategies. Instructions can entirely (and thus believe they can do anything, but vary from general guidelines (“When you are check- just do not want to) or have rebelled completely (and ing whether your thoughts fit the facts, be sure to thus never entertain the possibility that motivational check out the probability that the dire consequences factors might be as important as ability-­related fac- will occur”) to very specific suggestions as to what tors). These therapy dilemmas are discussed more the client should do (“The minute an urge hits, go fully in the next chapter. get a cold gel pack and hold it in your hand for 10 To assess whether a behavioral pattern is within a minutes”) or think (“Keep saying over and over to client’s repertoire, the skills trainer has to figure out yourself, ‘I can do it’ ”). Especially in a group set- a way to create ideal circumstances for the client to ting, instructions can be presented in a lecture for- produce the behavior. For interpersonal behaviors, mat with a blackboard or whiteboard as an aid. an approximation to this is role playing during the Instructions can be suggested as hypotheses to be skills training session—or, if the client refuses, ask- considered, can be set forth as theses and antitheses ing the client to indicate what he or she would say in to be synthesized, or can be drawn out in a Socratic a particular situation. Alternatively, one client can method of discourse. In all cases, a trainer must be be asked to coach another during a role play. I am careful not to oversimplify the ease of behaving ef- frequently amazed to find that individuals who ap- fectively or of learning the skill. With adolescents, pear very interpersonally skilled cannot put together it can be very useful to let them read sections of reasonable responses in certain role-play situations, the skills handouts out loud before you launch into whereas individuals who seem passive, meek, and specific instructions and examples. In my groups, unskilled are quite capable of responding skillfully hands ordinarily shoot up when I suggest this. With if the role play can be made comfortable enough. individuals who have already learned a skill once, In analyzing distress tolerance, the trainer can ask you can ask for volunteers to describe it, including what techniques the client uses or thinks helpful in how it might be used and for what. You can add tolerating difficult or stressful situations. Emotion comments and examples as necessary. regulation can sometimes be assessed by interrupt- As the skills are taught, it is critical to attempt ing an exchange and asking whether the client can to link each skill to its intended outcome. For ex- change his or her emotional state. Self-­management ample, in teaching relaxation, skills trainers should and mindfulness skills can be analyzed by observing describe not only how relaxation works but when clients’ behavior in sessions, especially when they it works, why it works, and what it works for. It is are not the focus of attention, and questioning them also useful to discuss when it doesn’t work, why it about their day-to-day behavior. may not work, and how to make it work when it If a client produces a behavior, the skills trainer seems not to be working. The more trouble trainers knows it is in the person’s repertoire. However, if can predict in advance, the better clients are likely the client does not produce it, the trainer cannot be to learn the skill. sure; as in statistics, there is no way to test the null It is particularly important to remember that im- hypothesis. When in doubt, it is usually safer to pro- mediate emotional relief is not the goal of every ceed with skill acquisition procedures just in case, skill taught in DBT skills training. This distinction and then observe any consequent change in behav- is often not grasped by either clients or new skills ior. Generally there is no harm in doing so, and most trainers. In fact, when clients say that something 68 I. AN INTRODUCTION TO DBT SKILLS TRAINING didn’t work, they almost always mean that it didn’t priate interpersonal behavior. When events between make them feel better immediately. Thus the rela- a trainer and the client arise that are similar to tionship of skills to long-term goals versus short- events the client encounters in his or her natural term goals, and to long-term relief versus immedi- environment, the trainer can model handling such ate relief, has to be discussed over and over. It is situations in effective ways. The skills trainer can particularly important not to be pulled into always also use self-talk (speaking aloud) to model coping trying to show how a skilled behavior will make a self-­statements, self-­instructions, or restructuring of person feel better right away. First, it isn’t usually problematic expectations and beliefs. For example, true; second, even if it were true, it is not necessarily the trainer may say, “OK, here’s what I would say to beneficial. myself: ‘I’m overwhelmed. What’s the first thing I do when I’m overwhelmed? Break down the situation into steps and make a list. Do the first thing on the Using the Handouts list.’ ” Telling stories, relating historical events, or The skills training handouts available on the special web- providing allegorical examples (see Chapter 7 of the site for this manual (www.guilford.com/lin-manual) main DBT text) can often be useful in demonstrat- provide written instructions. It is important, how- ing alternative life strategies. Finally, self-­disclosure ever, to note that you do not have to repeat every can be used to model adaptive behavior, especially word on each handout during a skills session. The if a skills trainer has encountered problems in living written handouts function as cues for your teach- similar to those a client is currently encountering. ing and as reminders for clients of what and how Particularly useful are well-told dramatic and/or hu- to practice the skillful behaviors when they are not morous teaching stories based on a skills trainer’s in skills sessions. For example, many participants running into a problem and then figuring out how have commented that they carry their skills bind- to use skills to solve the problem. In our experi- ers with them, so that when they forget what skill ence, clients love these stories, tell them to others, to use or how to use a skill, they can look it up on and—­because they often remember a skills trainer’s the handouts. One of our clients once told his wife stories better than the handouts—use the stories during an argument that she had to wait a minute to remind themselves of how to use the skills. As I while he went out to check his skills book. Within have said many times in my program, “If you want sessions, many of the handouts are designed to en- to get to know our skills trainers really well, just courage participants to check off goals and the new watch them teach skills. You will find out how they behaviors they plan to practice. Handouts also pro- used skills to overcome almost all problems in their vide a place for clients to take notes. For many cli- lives.” This tactic is discussed at length in Chapter ents, this latter function is particularly important. 12 of the main DBT text, and careful attention to When I have updated handouts and tried to replace the guidelines listed there is recommended. old handouts with new ones, clients routinely want All of the modeling techniques described above, to keep their old ones (as well as their old, filled-out of course, can also be used in a group context by worksheets). members modeling for one another. The ideal is for one group member to demonstrate in front of the whole group how to handle a situation skillfully. Modeling The more comfortable group members are with one Modeling can be provided by trainers, other clients, another and with the group leader, the easier it is to or other people in a client’s environment, as well induce them to act as models. Humor and flattery as by audio or video recordings, films, or printed can be great aids here. material. Any procedure that provides a client with In addition to in-­session modeling, it can be useful examples of appropriate alternative responses is a to have clients observe the behavior and responses form of modeling. The advantage of a skills train- of competent people in their own environments. The er’s providing the modeling is that the situation and behaviors that they observe can then be discussed in materials can be tailored to fit a particular client’s sessions and practiced by everyone. The skills train- needs. ing handouts provide models of how to use specific There are a number of ways to model skilled be- skills. Biographies, autobiographies, and novels havior. In-session role playing (with the skills trainer about people who have coped with similar problems as a participant) can be used to demonstrate appro- provide new ideas as well. It is always important to  4. Skills Training Treatment Targets and Procedures 69 discuss with the clients any behaviors modeled by control physiological responses, clients may practice the skills trainers or other clients, or presented as relaxing during a session. When clients are learning models outside of therapy, to be sure that the clients the skill of checking the facts, the leaders can start are observing the relevant responses. a round robin and ask each client to generate a new One goal of the skills training sessions is to im- interpretation of facts about an event. When specific part information about particular coping strategies problems are presented, clients can be encouraged to participants. A second, equally important goal is to problem-solve and/or to describe how they would to elicit from the participants rules and strategies for cope ahead with the problem situation. When cli- effective coping that they have learned in the partic- ents are learning radical acceptance, they can be ular situations they encounter. Thus skills training instructed to write down the important and less im- should be taught so that the instructional material portant things in their lives they need to accept on is augmented as a result of each discussion. Partic- the worksheet provided, and then share what they ipants should be encouraged to take notes and to have written with the group. expand the handouts and worksheets furnished dur- Covert response practice may also be an effective ing sessions with their own and other participants’ form of skill strengthening. It may be more effec- ideas. Whenever a particularly good strategy is pre- tive than overt methods for teaching more complex sented in a session, all (including the skills training skills, and it is also useful when a client refuses leaders) should be instructed to write it down in the to engage in overt rehearsal. Whereas clients can appropriate space on their handouts or worksheets. be asked to practice emotion regulation generally, The strategy should then be included in practice and “emotional behavior” cannot be practiced directly. review, just as are strategies presented initially by That is, clients cannot practice getting angry, feel- the leaders. ing sad, or experiencing joy. Instead, they have to practice specific components of emotions (changing facial expressions, generating thoughts that elicit or Skill Strengthening inhibit emotions, changing muscle tension, etc.). In Once skilled behavior has been acquired, skill my experience, adults with emotion dysregulation strengthening is used to shape, refine, and increase rarely like behavioral rehearsal, especially when it the likelihood of its use. Without reinforced prac- is done in front of others. Thus a fair amount of tice, a skill cannot be learned; this point cannot be cajoling and shaping will be needed. If a client won’t emphasized too much, since skill practice is effort- role-play an interpersonal situation, for example, ful behavior and directly counteracts the tendencies a skills trainer can try talking him or her through of individuals with disordered emotion regulation to a dialogue (“Then what could you say?”). The cli- employ a passive behavior style. ent can also be asked to try practicing just part of a new skill, so that it is not overwhelming. The es- sence of the message is that in order to be different, Behavioral Rehearsal people must practice acting differently. Some train- “Behavioral rehearsal” is any procedure in which a ers do not like behavioral rehearsal either, especially client practices responses to be learned. This can be when it requires them to role-play with the clients. done in interactions with trainers or other clients, For trainers who feel shy or uncomfortable, the best and in simulated or in vivo situations. Any skilled solution is for them to practice role playing with behaviors—verbal sequences, nonverbal actions, members of their DBT therapist consultation team. patterns of thinking or cognitive problem solving, At other times, trainers resist role playing because and some components of physiological and emo- they do not want to push rehearsal on clients. These tional responses—can, in principle, be practiced. trainers may not be aware of the wealth of data in- Practice can be either “overt” or “covert.” Co- dicating that behavioral rehearsal is related to thera- vert practice is practicing the requisite response in peutic improvement. imagination and is discussed further below. Overt practice is behavioral rehearsal; various forms are Response Reinforcement possible. For example, in a group context, group members may role-play problematic situations (to- Trainers’ reinforcement of clients’ responses is one of gether or with the leaders), so that each member the most powerful means of shaping and strength- can practice responding appropriately. To learn to ening skilled behavior. Many individuals have lived 70 I. AN INTRODUCTION TO DBT SKILLS TRAINING in environments that overuse punishment. They financially feasible. We have no research data on our often expect negative, punishing feedback from the sticker strategy, but we have definitely noticed an world in general and their therapists in particular, improvement in homework completion since we put and apply self-­punishing strategies almost exclusive- the policy in place. ly in trying to shape their own behavior. Over the What is important is that once you have outlined long run, skill reinforcement by trainers can modify specifically and clearly what behaviors are required the clients’ self-image in a positive manner, increase for specific reinforcers, you must stick to your deci- their use of skilled behavior, and enhance their sions and not reinforce behavior that does not meet sense that they can control positive outcomes in the criteria you have clearly identified. It is equal- their lives. One of the benefits of group therapy over ly important not to skip analyzing failures to do individual therapy is that when a group leader ac- homework because you are worried about how an tively and obviously reinforces a skilled behavior in individual will react. See the section on managing one group member, the same behavior is vicariously homework review later in this chapter for more on reinforced among all other group members (if they this topic. If no one or only a few individuals consis- are attending). In other words, this provides “more tently meet criteria for reinforcement, then you need bang for the buck.” Moreover, group therapy can be either to change your criteria for it or to consider very powerful when group members become adept switching to shaping as a strategy. at reinforcing skilled behaviors in one another. Skills trainers need to stay alert and notice client The techniques of providing appropriate rein- behaviors that represent improvement, even if these forcement are discussed extensively in Chapter 10 make the trainers rather uncomfortable. For exam- of the main DBT text. Those principles are very im- ple, teaching clients interpersonal skills to use with portant and should be reviewed thoroughly. Note their parents, and then punishing or ignoring those that “reinforcement” refers to all consequences or same skills when the clients use them in a training contingencies that increase the probability of a be- session, is not therapeutic. Encouraging clients to havior. Although reinforcers are typically thought think for themselves, but then punishing or ignor- of as generally positive, desirable, or rewarding ing them when they disagree with a trainer, is not events, they need not be. A reinforcer is anything therapeutic. Stressing that “not fitting in” in all cir- an individual will change his or her behavior to get cumstances is not a disaster and that distress can be or to have removed. A positive reinforcer is a posi- tolerated, and then not tolerating clients when they tive event that is added, and a negative reinforcer is do not fit comfortably into a trainer’s schedule or a negative event that is taken away. Reinforcers can preconceived notions of how individuals with emo- be naturally occurring consequences of behavior, or tion dysregulation act, is not therapeutic. arbitrary events determined by the individual pro- viding the reinforcement, or (better yet) negotiated Feedback and Coaching with the individual who is being reinforced. Identi- fication of concrete reinforcers is necessary for each “Feedback” is the provision of information to clients individual client. In our groups, we use both natural about their performance. Feedback should pertain to and arbitrary reinforcers. For example, individuals performance, not to the motives presumably leading who complete worksheets between sessions get one to the performance. This point is very important. sticker (an arbitrary positive reinforcer) per page, An unfortunate factor in the lives of many individu- and if they use the skill but don’t write it down on als with severe emotion dysregulation is that people the worksheet they get half of a sticker; two half rarely give them feedback about their behavior that stickers get one complete sticker. If they complete is uncontaminated with interpretations about their all of the worksheets assigned for homework, they presumed motives and intent. When the presumed also avoid being asked assessment questions about motives do not fit, the individuals often discount or the missing homework. In our experience, many are distracted from the valuable feedback they may clients will work at homework just to avoid being be getting about their behavior. Feedback should be questioned about how it was that they did not do behaviorally specific; that is, a skills trainer should the homework. We also reinforce participants with tell the client exactly what he or she is doing that one sticker if they arrive on time for skills train- seems to indicate either continuing problems or ing. Generally we keep on hand a large number of improvement. Telling clients that they are manipu- stickers of all kinds; we provide favored stickers if lating, expressing a need to control, overreacting,  4. Skills Training Treatment Targets and Procedures 71 clinging, or acting out is simply not helpful if there when problem behaviors show up during skills are not clear behavioral referents for the terms. This training sessions. is, of course, especially true when a trainer has pin-­ pointed a problem behavior correctly but is mak- Skill Generalization ing inaccurate motivational inferences. Many argu- ments between clients and trainers arise out of just DBT does not assume that skills learned in therapy this inaccuracy. The role and use of interpretation will necessarily generalize to situations in every- in DBT are discussed extensively in Chapter 9 of the day life outside of therapy. Therefore, it is very im- main DBT text. Learning to tell the difference be- portant that skills trainers actively encourage this tween behaviors observed and interpretations about transfer of skills. There are a number of specific behavior is also an important part of the mindful- procedures that skills trainers can use as well, as de- ness “what” skill of describing (see Mindfulness scribed below. Handout 4 for a description of the “what” skills). A skills trainer must attend closely to a client’s Between-­Session Consultation behavior (within sessions or self-­reported) and se- lect those responses on which to give feedback. At If clients are unable to apply new skills in their natu- the beginning of skills training, the client may do ral environment, they should be encouraged to get little that appears competent; the trainer is usually consultation from their individual therapists, case well advised at this point to give feedback on a lim- managers, counselors, or from supportive family ited number of response components, even though members (particularly if family members are also other deficits could be commented upon. Feedback learning DBT skills); and from one another between on more may lead to stimulus overload and/or dis- sessions. Skills trainers can give these individuals couragement about the rate of progress. A response-­ lessons on how to provide appropriate coaching. In shaping paradigm should be used, with feedback, some areas, crisis line personnel may also be able to coaching, and reinforcement designed to encour- coach DBT skills. On residential, inpatient, and day age successive approximations to the goal of effec- treatment units, clients can be encouraged to seek tive performance (see Interpersonal Effectiveness assistance from staff members when they are having Handout 20, as well as Chapter 10 of the main DBT difficulty. Another technique is to provide a unit be- text). Individuals with disordered emotion regula- havioral consultant with regular office hours. This tion often desperately want feedback about their be- consultant’s task is to help clients apply their new havior, but at the same time are sensitive to nega- skills to everyday life. tive feedback. The solutions here are for trainers to surround negative feedback with positive feedback, Review of Session Video Recordings to normalize skills deficits by telling stories about themselves or others who have had the same prob- If possible, video recordings of skills training ses- lems, and/or to cheerlead with encouraging state- sions should be made. The videos can then be re- ments. Treating clients as too fragile to deal with viewed by clients between sessions if there is a negative feedback does them no favor. An important room available where they can come and watch part of feedback is giving clients information about them. (Because of confidentiality concerns, it is im- the effects of their behavior on their skills trainers; portant for clients not to take videos out of your this is discussed more extensively in Chapter 12 of clinical setting.) There are several benefits to clients the main DBT text. in watching video sessions. First, clients are often “Coaching” is combining feedback with instruc- unable to attend to much of what transpires dur- tions. It is telling a client how a response is discrep- ing skills training sessions because of substance ant from the criterion of skilled performance and use prior to sessions, high emotional arousal dur- how it might be improved. Clinical practice suggests ing sessions, dissociation, or other concentration that the “permission” to behave in certain ways that difficulties accompanying depression and anxiety. is implicit in coaching may sometimes be all a client Thus clients may improve their retention of material needs to accomplish changes in behavior. Coaching offered during the sessions by viewing the session is ordinarily integrated into homework review. It videos. Second, clients may gain important insights is also used when trainers are helping clients apply from viewing themselves and their interactions with skills they are learning to their everyday lives, and others. Such insights often help clients understand 72 I. AN INTRODUCTION TO DBT SKILLS TRAINING and improve their own interpersonal skills. Third, can also revise these to fit either their clients’ or many clients report that watching a skills training their own personal preferences and needs. video can be very helpful when they are feeling over- whelmed, panicked, or unable to cope between ses- Use of Assignment Worksheets sions. Simply watching a video, especially if the cli- and Diary Cards ent can watch one of a session where a needed skill was taught, has an effect similar to that of having an The first half of every skills training session is devot- additional session. Skills trainers should encourage ed to review of homework, as described in Chapter use of the videos for these purposes. 3. This is how trainers check on clients’ behavioral progress (or lack of it) between sessions and pro- vide necessary feedback and coaching. It is essential Use of DBT Web-Based Resources, DVDs, that homework review, including providing indi- and DBT Skills Apps vidualized feedback and coaching, not be skipped. Over the years I have developed a series of skills When review is skipped, clients are not reinforced training videos that clients can either buy or borrow for their practice, and over time practice is likely to to take home and watch. My experience teaching drop off. When review is limited to what skills were DBT skills has been that even when I am the skills practiced, and individual feedback and coaching on leader, participants often also like watching me skills use are skipped, little may be learned. This is teach the same skill on a video. At times watching equivalent to a piano teacher’s checking to see that them, I have thought my own videos are better than the student practiced during the week, but never lis- me. There are now many self-help websites for DBT tening to the student play the piece that was prac- skills; many of these give DBT skills instructions, as ticed. Little progress can be expected when such well as examples of using them in daily life. Smart- is the case. The primary method of tracking skills phone apps on DBT are proliferating as well; most practice is by reviewing the worksheets assigned at of these apps are set up to provide mobile coaching the previous session. DBT diary cards should also in skills use. Look up DBT apps on your carrier. be reviewed when clients are in DBT skills training My online video and audio recordings can be only (i.e., are not in an individual therapy where found in a number of places. Try the video page of skills use is routinely evaluated). The DBT diary the Behavioral Tech website (http://behavioraltech. card (Figure 4.1) lists the most important DBT skills org/products/list.cfm?category=Videos), or look taught. The top half of the diary card is reviewed in up “Linehan DBT videos” and “DBT self-help” on individual therapy, and the bottom half can be re- your search engine, on YouTube, or on iTunes. viewed in both individual therapy and skills training sessions. For clients in a skills-only program and for parents in a multifamily skills group, use only the In Vivo Behavioral Rehearsal: bottom half of the diary card, which covers some Homework Assignments of the most important skills. Next to each skill is a Homework assignments are keyed to the specific space for daily recording of whether or not the client behavioral skills currently being taught. It is advan- actually practiced the skill that day. (See Table 4.2 tageous if a skills trainer or a client can also get for instructions in helping a client to use the diary the client’s individual therapist to use some of the cards.) If multiple members of a family are filling homework assignments and accompanying work- out the diary card each week, it can be useful for sheets throughout therapy, or on an as- needed basis. them to attach the cards to the kitchen refrigerator This is always done in standard DBT. For example, or some other public place. In addition, diary sheets one worksheet focuses on identifying and label- can be created for each skills training module and ing emotions and takes clients through a series of given to clients as the need arises. A weekly review steps to help them clarify what they are feeling. The of the diary card is important, because if only the individual therapist may suggest that a client use previous week’s homework is reviewed, there is a this form whenever he or she is confused or over- danger that skills taught previously will drop off the whelmed by emotions. The website for this book client’s radar and not be practiced. Not bringing in (www. guilford.com/lin-manual) contains multiple the diary card (when diary cards are reviewed), or worksheets covering each of the DBT behavioral reporting no practice effort or skills application, is skills but skills trainers and individual therapists viewed as a problem in self-­management and is ana-  Dialectical Behavior Therapy Diary Card Name: Filled Out in Session? How Often Did You Fill Out? Last Day Filled Out: Daily 2–3× Month Year Y N 4–6x Once Day Circle Highest Rating Start Highest Urge To: for Each Day Drugs/Medications Actions Emotions Optional Day p.r.n./Over- Commit Self- Use Emotion Physical Illegal Meds. as the-Counter Self- Used Day Suicide Harm Drugs Misery Misery Joy Alcohol Drugs Prescribed Meds. Harm Lied Skills* of week 0–5 0–5 0–5 0–5 0–5 0–5 # What? # What? Y/N # What? Y/N # 0–7 MON TUE WED THUR FRI SAT SUN Med. Change This Week *Used Skills 0 = Not thought about or used 5 = Tried, could use them, helped 1 = Thought about, not used, didn’t want to 6 = Automatically used them, 2 = Thought about, not used, wanted to didn’t help 3 = Tried but couldn’t use them 7 = Automatically used them, Homework Assigned and Results This Week: 4 = Tried, could do them but they didn’t help helped Coming into Session Belief I Can Change or Coming into Urges to: (0–5) Regulate My: Session (0–5) Quit Therapy Emotions Use Drugs Actions Commit Suicide Thoughts Skills Focus This Week: DBT Diary Card Filled out this card? Daily 2–3× 4–6x Once In session Check skills; circle days skill was practiced Wise mind MON TUE WED THUR FRI SAT SUN Observe: Just notice MON TUE WED THUR FRI SAT SUN Describe: Put words on, just the facts MON TUE WED THUR FRI SAT SUN Mindfulness Participate: Enter into the experience MON TUE WED THUR FRI SAT SUN Nonjudgmentally MON TUE WED THUR FRI SAT SUN One-mindfully: Present moment MON TUE WED THUR FRI SAT SUN Effectively: Focus on what works MON TUE WED THUR FRI SAT SUN PLEASE (Care: PhysicaL ills, Eating, Avoid mood-altering substances, Sleep, Exercise) DEAR MON TUE WED THUR FRI SAT SUN TIP (Temperature, Intense Exercise, Paced Breathing, Paired muscle relaxation) MAN MON TUE WED THUR FRI SAT SUN GIVE MON TUE WED THUR FRI SAT SUN Interpersonal Effectiveness FAST MON TUE WED THUR FRI SAT SUN Walked the middle path; Dialectics MON TUE WED THUR FRI SAT SUN ABC (Accumulate positive emotions, Build mastery, Cope ahead) Validation MON TUE WED THUR FRI SAT SUN Strategies to change behavior MON TUE WED THUR FRI SAT SUN Checked the facts MON TUE WED THUR FRI SAT SUN Did opposite action MON TUE WED THUR FRI SAT SUN Problem-solved MON TUE WED THUR FRI SAT SUN FAST (Fair, no Apologies, Stick to values, Truthful) GIVE (Gentle, Interested, Validate, Easy manner) Emotion Accumulated positive emotions A MON TUE WED THUR FRI SAT SUN MAN (Mindful, Appear confident, Negotiate) Regulation Built mastery B MON TUE WED THUR FRI SAT SUN DEAR (Describe, Express, Assert, Reinforce) Coped ahead C MON TUE WED THUR FRI SAT SUN Reduced vulnerability: PLEASE MON TUE WED THUR FRI SAT SUN Mindfulness of current emotion MON TUE WED THUR FRI SAT SUN CRISIS STOP skill MON TUE WED THUR FRI SAT SUN SURVIVAL Pros and cons MON TUE WED THUR FRI SAT SUN TIP MON TUE WED THUR FRI SAT SUN Distracted MON TUE WED THUR FRI SAT SUN Distress Tolerance Self-soothed MON TUE WED THUR FRI SAT SUN Improved the moment MON TUE WED THUR FRI SAT SUN REALITY Radical acceptance MON TUE WED THUR FRI SAT SUN ACCEPT Half-smiling, Willing Hands MON TUE WED THUR FRI SAT SUN Willingness, Mindfulness of Current Thoughts MON TUE WED THUR FRI SAT SUN FIGURE 4.1. Front (top) and back (bottom) of a DBT diary card. The entire back half of the card is used in skills train- ing sessions; the front half is used in individual therapy except for the “Used Skills” column, which is also employed in skills training. Should be printed on 4" × 6" card stock (front and back). From DBT Skills Training Manual, Second Edition, by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan. Permission to photocopy this diary card is granted to purchasers of this book for personal use or for use with clients.  TABLE 4.2. Instructions for Helping a Client Complete the DBT Diary Card 1. Name: Put here the client’s name, initials, or clinical client didn’t use any prescription meds. this ID. week, a vertical line down the “Y/N” column under “Meds. as Prescribed” is OK. Or if the 2. Filled Out In Session? If the card was filled out client didn’t use alcohol, over-the-­counter meds., during the session, have the client circle “Y” for or prescription meds. on Wednesday, then a “yes”; otherwise circle “N” for “no.” horizontal line may be drawn through the corresponding boxes for Wednesday. 3. How Often Did You Fill Out [This Side]? In the past week, did the client fill out the card daily, 2–3 10. Actions... : The column “Self-Harm” refers to any times, or once? intentional self-harm or suicide attempt. The “Lied” column refers to all overt and covert behaviors that 4. Date Started: Ask the client to note the first date the mask telling the truth. It’s important for the client card was started, including year. to assume a nonjudgmental stance in completing this. Instruct the client to put the number of lies told per day in the column, and place an * in this 5. Day of Week: Instruct the client to record column to signify lying on the diary card. The Used information for each day of the week. Skills (0–7) column is used to report the highest skill usage for the day. When making this rating, the 6. Using the 0–5 Rating Scale: You’ll notice that client should refer to the 0–7 “Used Skills” table just many of the columns require the client to record a under the columns. numerical value from 0 to 5. This is a subjective, The last two columns are optional. Two columns continuous scale intended to communicate the are for tracking specific emotions, and two are for client’s experience along a variety of behaviors or any other behaviors you and the client want to track. experiences. The anchor point 0 represents the Note that there is not a rating scale for these, so absence of a particular experience (e.g., no urge); the when you and the client are deciding what to track, anchor point 5 refers to the strongest degree of the also decide how to track it—for example, with a experience (e.g., strongest urges imaginable). “Y,” “N,” a 0–5 or 0–7 scale, or by describing what and how much (i.e., “What?” and #). 7. Urges to... : The “Commit Suicide” column refers to any urges to commit suicide. The “Self-Harm” 11. Med. Change This Week: Instruct the client to write column refers to urges to engage self-harm or in any down any changes in prescribed medications. These self-­injurious behaviors. The “Use Drugs” column changes may consist of modifications in the dosage refers to use of any drug of abuse (e.g., over-the-­ (increase or decrease) of the medications (e.g., counter meds., prescription meds., street/illicit increase from 5 mg to 10 mg; a decrease from 20 drugs)—or, for clients not using drugs to any urge to mg to 10 mg), the dropping of a medication, or the escape. addition of a new medication. If there is insufficient room, the client should describe these on a separate 8. Highest Ratings refers to ratings of intensity of piece of paper. emotional misery, intensity of physical misery or pain, and degree of joy (or happiness) experienced 12. Homework Assigned and Results This Week: Have during the day. Have the client rate each emotion the client record any behaviors assigned for the daily, using the 0–5 rating scale. week, describe what was done, and indicate what the results were. 9. Drugs/Medications: For alcohol, have the client put down how many drinks and what type of alcohol (e.g., “3” for 3 beers). For illegal drugs, have the 13. Urges to Use (0–5) and Urges to Quit Therapy client specify the type of drug used (e.g., heroin) (0–5): Have the client rate the intensity of current and how much was used. For p.r.n./over-the-­counter urges to engage in these behaviors, at the beginning medications, have the client put down how many of the session. doses and what type of medication was taken. For meds. as prescribed, if taken as prescribed, have the 14. Skills Focus This Week: Instruct the client to write client put a “Y” for yes; if not taken as prescribed down any skills that are specifically focused on, (either too much or too little, or some medications used, or practiced during the week. This space can but not others), have the client put down an “N” for also be used to write down what skills need more no. focus during the week. Write “ditto” marks in subsequent specify boxes, 15. Belief I Can Change or Regulate... : Using the to indicate use is the same as the previous day. same 0–5 rating scale, rate your belief regarding An Easier Way: The client can use horizontal your ability to change or regulate your emotions, lines through rows and vertical lines through actions, and thoughts as you start your therapy columns to indicate no use. For instance, if the session. 74  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