DBT Skills Training Provider Roles PDF

34 I. AN INTRODUCTION TO DBT SKILLS TRAINING any group process. Once again, I have not found course, a threatening experience for a person who is this to be the case. working hard at avoiding dysfunctional patterns of...

34 I. AN INTRODUCTION TO DBT SKILLS TRAINING any group process. Once again, I have not found course, a threatening experience for a person who is this to be the case. working hard at avoiding dysfunctional patterns of behavior. In addition, we have found that as clients progress in therapy, they often begin to change their Arguments for a Homogeneous Group self-image from that of “person with a disorder” to From my perspective, there are two powerful argu- that of “normal person.” Especially if they are very ments for a homogeneous group. First, homogeneity judgmental, they can find it very hard to stay in a allows the group leaders to tailor the skills and theo- group defined as a group for disordered individuals. retical conceptions they offer to the specific prob- These two issues—the urge to imitate dysfunctional lems of group members. Most of the skills taught behavior, and the need to change one’s self-image are applicable for many client populations. Howev- from “disordered” to “not disordered”—must be er, a heterogeneous group requires a much more ge- dealt with effectively by the group leaders if an indi- neric presentation of the skills, and the application vidual is to continue with the group. of the skills to each person’s central problems has to be worked out individually. With a homogeneous group, examples can be given that reflect their spe- Clarifying Providers’ Roles cific problems and situations. A common conceptual Skills Group Leaders scheme would be difficult to present in a heteroge- neous group unless it was very general. In standard DBT groups, we use a model of a pri- A second argument for a homogeneous group is mary group leader and a co-­leader. The functions the opportunity for clients to be with a group of indi- of the two leaders during a typical session differ. viduals who share the same problems and concerns. The primary leader begins the meetings, conducts In my experience, this is a very powerful validating the initial behavioral analyses of homework prac- experience for our clients. Many have been in other tice, and presents new material about skills. The pri- groups but have not had the experience of being mary group leader is also responsible for the timing around others like themselves. For those with BPD of the session, moving from person to person as time and other severe disorders, they may have finally allows. Thus the primary group leader has overall found others who actually understand the often in- responsibility for skills acquisition. explicable urges to injure themselves, the desire to The co-­leader’s functions are more diverse. First, be dead, the inability to regulate anger, the power he or she mediates tensions that arise between mem- of urges to use drugs, the inability to pop out of a bers and the primary leader, providing a balance depressed mood, the frustration of being unable to from which a synthesis can be created. Second, while control emotions and behavior, or the pain of emo- the primary group leader is looking at the group as a tionally invalidating experiences. Adolescents have whole, the co-­leader keeps a focus on each individ- found others who understand their difficulties with ual member, noting any need for individual atten- parents, the pain of being bullied, their intense desire tion and either addressing that need directly during to be acceptable, and their beliefs that they are not. group sessions or consulting with the primary leader In a group for friends and family members, clients during breaks. Third, the co-­leader serves as a co-­ share the pain of having loved ones suffering and the teacher and tutor, offering alternative explanations, frequent sense of desperation and helplessness. examples, and so on. The co-­leader may move his A factor that can complicate the advantage of or her seating around the group as needed to assist having an entire group of individuals with the same participants in finding the right handouts or work- disorder or problem has to do with different rates sheets or to provide needed support. The co-­leader is of individual progress in treatment. When one cli- often the person who keeps track of the homework ent is engaging in dysfunctional behaviors, it is very assignments. This is especially important when spe- validating to have other group members struggling cial individual assignments are given to one or more with the same issue. However, once the client has participants in the group. In these cases, it is also stopped such behaviors, it can be very hard if oth- the co-­leader who is charged with remembering the ers are still engaging in the same behaviors. Hear- various assignments. ing about others’ out-of-­control behavior seems to Generally, if there is a “bad guy,” it is the primary cause a greater urge to do the same thing; this is, of group leader, who enforces the group norms; if there  2. Planning to Conduct DBT Skills Training 35 is a “good guy,” it is the co-­leader, who always tries Individual Skills Trainers to see life from the point of view of a person who is In individual skills training, the skills trainer plays “down.” More often than not in a group meeting, the role of both the skills leader and the co-­leader as though not always, the person who is “down” is a described above. It is extremely important in indi- group member; thus, the “good guy” image emerges vidual work that the skills trainer stick to the role of for the co-­leader. As long as both leaders keep the teaching skills, while balancing teaching with neces- dialectical perspective of the whole, this division of sary troubleshooting of problems in learning skills labor and roles can be quite therapeutic. Obviously, and skills use that arise. Although an individual it requires a degree of personal security on the part skills trainer is not an individual therapist, it is ap- of both therapists if it is to work. propriate for such a trainer to suggest specific skills The DBT consultation strategies can be especially for problems that clients present, such as opposite important here. The DBT consultation team serves action when a client is avoiding something or cope as the third point providing the dialectical balance ahead when a client is afraid of failing at something. between the two co-­leaders, much as the co-­leader That said, it is important for an individual skills does between the primary leader and a group mem- trainer not to fall into the role of being an individual ber in a group session. Thus the function of the DBT therapist. The best way to avoid this is always to consultation team is to highlight the truth in each keep in mind the mantra of “What skills can you side of an expressed tension, fostering reconciliation use?” and synthesis. Over the years, many DBT teams have tried to convince me that one skills leader is all that is needed DBT Individual Therapists for most groups. I remain unconvinced. With highly An individual therapist for a person in skills train- dysregulated and/or suicidal individuals, a co-­leader ing is the primary treatment provider and as such is invaluable as a person who can leave the room if is responsible for overall treatment planning; for needed to block a suicidal person from carrying out management of crises, including suicidal crises; for a suicide threat, go and get an ice pack for a person taking as-­needed coaching and crisis calls or arrang- with extreme arousal, validate a person who feels ing for another provider to take these calls; and for attacked by the leader, or coach one person during a making decisions on modifications to treatment, in- break while the leader coaches another. In a multi- cluding how many complete rounds of skills train- family group, the co-­leader can coach the adolescent ing the individual should be in, whether admission while the leader nudges a parent to practice his or to a higher level of care is necessary, and so forth. her skills with the adolescent. In groups for friends Except in a crisis to avoid serious injury or death, and family members, as well as other groups where skills trainers turn crisis management over to indi- participants have no identified mental disorders, it is vidual therapists. surprising how helpful a co-­leader can be in attend- The task of the therapist with an individual in ing to the process issues that often arise. In sum, skills training also includes applying the lens of be- managing a group in skills training is a complex havioral skills to helping clients generate solutions task. Finally, there is no substitute for having an ob- to their problems. Indeed, when confronted with a server of one’s own behavior and skills as a group client’s problem, a well-­trained clinical provider can leader or co-­leader. For example, due to my work find an approach to problem solving by using skills schedule and one skills training group’s meeting in from each skills module. Thus, when Distress Toler- the evening, I was coming into group sessions as the ance is the current treatment module (or a distress primary leader with very little energy, looking tired tolerance skill is what the therapist wishes the client and sounding uninteresting. Naturally, this did not to practice), problems may be viewed as ones where bode well for a successful skills training session. My distress tolerance is needed. If interpersonal effec- co-­leader brought it up with me, and we decided on tiveness is the focus, then the individual provider a plan to “rev me up” each week (drinking a cold may ask how the problem (or the solution) might be cola right before group). Now my co-­leader not only related to interpersonal actions. Generally, problems reminds me each week, but also gives me feedback become “problems” because the events are associ- at break if I need to make a greater effort at “com- ated with aversive emotional responses; one solution ing alive.” 36 I. AN INTRODUCTION TO DBT SKILLS TRAINING may be for the client to work on changing emotional ber can more effectively provide suggestions for a responses to a situation. An effective response may more skillful response or can more clearly intervene also be cast in terms of radical acceptance or core in the contingencies surrounding the behavior. mindfulness skills. DBT Pharmacotherapists DBT Case Managers The primary duties of a pharmacotherapist (whether If a client has no individual psychotherapist, a DBT a psychiatrist or a nurse practitioner) are to provide case manager is the primary provider and is responsi- evidence-based medications matched to the needs ble for all the tasks outlined above for the individual of each client, and to monitor compliance with the therapist. In addition, although both psychothera- prescribed medication regimen as well as outcomes pists and case managers focus on clinical assessment, and side effects. For a DBT pharmacotherapist, a planning, and problem solving, case managers are further essential task is to coach the client whenever ordinarily more active in facilitating care in the cli- possible in relevant DBT skills. DBT skills aimed at ent’s living environment. Thus the case manager’s treating physical illness, insomnia/nightmares, poor role also includes identification of service resources, nutrition, effects of drugs and alcohol, and lack of active communication with service providers, care exercise may seem to fit the role best, but it is equally coordination, and advocacy for options and services important to focus on the wide array of other DBT to meet an individual’s and family’s needs. In this skills as well. Like other providers, the pharmaco- role, the case manager not only helps identify appro- therapist (except in emergencies) also turns crisis priate providers and facilities throughout the con- intervention over to the primary provider (therapist tinuum of services, but also actively works with the or case manager), but until then often asks, “What client to ensure that available resources are being skills can you use until you get hold of him [or her]?” used in a timely and cost-­effective manner. In sum, In some settings, when there is no individual thera- in contrast to a DBT therapist, a case manager does pist or case manager, the DBT pharmacotherapist much more environmental intervention. As a DBT assumes the role of primary provider responsible for case manager, however, the task is to move more the tasks outlined above. In other settings, particu- to the center and increase use of “consultation-to- larly when contact with the pharmacotherapist is the-­patient” strategies (see below). The idea here is infrequent and clients are not known to have seri- to coach clients to actively engage in the tasks that ous disorders, the skills leader assumes the role of the case managers ordinarily do for the clients—in primary therapist. It is important that these roles be other words, to teach the clients to fish rather than discussed and clarified within the DBT team. catch the fish for them. This then involves coaching the clients in the interpersonal, emotion regulation, Skills Trainers’ Responsibilities distress tolerance, and mindfulness skills necessary with Primary Care Providers to be successful.3 The ability to apply any one of the behavioral skills to any problematic situation is at once important DBT Nurses and Line Staff and very difficult. Individual providers must them- The primary role of DBT nurses and line staff is to selves know the behavioral skills inside and out, and manage contingencies on inpatient and residential must be able to think quickly in a session or a crisis. units, to coach clients in the use of skills, and to use Given this role of the individual therapist, it is the DBT skills to problem-solve difficulties. Their role in responsibility of the skills trainers to be sure that the skill strengthening and generalization is often criti- individual therapist has access to skills the client is cal in milieu-based treatment programs. These pro- being taught. When an individual provider is not fa- viders often make extensive use of the chain analysis miliar with the skills being taught, the solution is to skill (described in Chapter 6), as assisting patients do what is possible to inform the therapist. General- with understanding the factors that prompt and ly this information, along with attendance and any drive their behaviors is typically accomplished with other important clinical information, is provided to more accuracy in the situation where the behaviors all DBT therapists at the weekly DBT team meet- occur. From this analysis, a nurse or line staff mem- ings. Strategies for this are discussed below.  2. Planning to Conduct DBT Skills Training 37 Consultation between DBT Individual on behalf of a client. Thus therapists must be careful Providers and Skills Trainers not to fall into the trap of serving as intermediaries for a client. (See Chapter 13 of the main DBT text Communication between individual DBT provid- for a discussion of consultation-to-the-patient strat- ers and skills trainers is exceptionally important. If egies; they are also discussed briefly in Chapter 5 of the expectations of each group of providers for the this manual.) other are not spelled out and frequently reviewed, it is very likely that the two treatments will not en- When the Primary Provider hance each other. Among the most important as- Is a Skills Trainer pects of DBT are the DBT consultation team strate- gies (described in Chapter 13 of the main DBT text). It is not uncommon that skills trainers are also in- These strategies require all DBT therapists to meet dividual therapists or case managers for some of on a regular basis. The goals of these meetings are to the clients in a skills training group. Less often, a share information and to keep therapists within the pharmacotherapist may also be a skills trainer for framework of DBT. his or her clients. When either of these is the case, In my clinic, a consultation meeting is held each it is important to keep roles clear. In other words, week for 1–1.5 hours. During the meeting, skills when one is teaching skills it is important to focus trainers review for the team which skills are the cur- on skills, and to wait until after the skills session rent focus of group sessions. When necessary, the ends to revert to one’s other role. This is not only skills trainers actually teach the other team mem- because of time constraints in a skills class, but also bers the skills. In this context, it is helpful for clients because as soon as skills trainers start managing if their primary providers and skills trainers share a crises, individual clients (particularly those whose common language in discussing application of be- lives involve constant crises) are likely to bring up havioral skills. This also decreases the potential for more crises to discuss and problem-solve. Focusing confusion. Although consistency and conformity on learning new behaviors can take a lot more effort between various treating agents are not particularly than sitting back and discussing the crises of life. valued in DBT, such consistency here can be useful, since the number of new skills to be learned is quite large. The weekly meetings increase this commu- DBT Skills Training nality. In addition, any problems individual clients outside Standard DBT may be having in applying skills and/or interacting in skills training group meetings are mentioned. A Standard DBT combines skills training with indi- client’s primary provider consults with the skills vidual therapy or intensive case management, plus trainers and takes such information into account in phone coaching by the individual provider and planning the individual treatment. weekly treatment team meetings. When DBT skills My emphasis on the importance of meetings be- training is offered without the individual provider tween individual therapists and skills trainers may component, some modifications in the conduct seem to contradict “consultation-to-the-­ patient” of skills training may be necessary. For example, strategies, which are also integral to DBT. First, I without an individual therapist, skills trainers may must point out that these consultation strategies do decide to provide phone, text, or e-mail coaching require DBT therapists to walk a very fine line. The between sessions. There may also be a greater em- issues are somewhat complex. When the therapeutic phasis on use of DBT smartphone coaching apps and unit is defined as a group of people, such as a DBT other DBT apps and websites. (To locate these, type team, a clinic, an inpatient unit, or some such en- “DBT self-help” in your search engine.) At times, tity where multiple therapists interact with and treat skills trainers may offer individual consultation ses- particular clients in a single coordinated treatment sions to group members. This may be particularly program, then consultation between therapists is es- necessary in groups for friends and family members, sential, provided that the clients are informed of and at times when group members are extremely dis- consent to such collaboration. Applying the consul- traught about a friend or relative and want and need tation strategies in these cases simply requires that more coaching in use of skills than can occur in a therapists refrain from intervening with each other single group session.