DBT Skills Training Strategies PDF

Chapter 5 Application of Fundamental DBT Strategies in Behavioral Skills Training The overarching strategy in DBT is the empha- together with the dialectical strategies, form the es- sis on dialectics at every turn in treatment. As can sential compon...

Chapter 5 Application of Fundamental DBT Strategies in Behavioral Skills Training The overarching strategy in DBT is the empha- together with the dialectical strategies, form the es- sis on dialectics at every turn in treatment. As can sential components of DBT. Communication strate- be seen in Figure 5.1, core DBT strategies are de- gies specify interpersonal and communication styles signed in pairs, representing acceptance on the one compatible with the therapy. Case management hand and change on the other. There are five major strategies specify how the therapist interacts with strategy categories: (1) the overarching dialectical and responds to the social network in which the cli- strategies; (2) core strategies (problem solving vs. ent is enmeshed. validation); (3) communication style strategies (ir- As can be seen in Figure 5.2, DBT is a modu- reverent vs. reciprocal); (4) case management strate- lar treatment. The key characteristic of a modular gies (consultation-to-the-­patient vs. environmental treatment is that the treatment provider can move intervention); and (5) integrative strategies. The the treatment strategies within various treatment core strategies of problem solving and validation, modules in and out of treatment as needed. Skills DIALECTICAL Stylistic Change Acceptance Irreverent Reciprocal Problem solving Validation Core Consultation to Environmental the patient intervention Team consultation Case management FIGURE 5.1. Treatment strategies in DBT. From Linehan, M. M. (1993). Cognitive-­behavioral treatment of borderline personality disorder. New York: Guilford Press. Copyright 1993 by The Guilford Press. Reprinted by permission. 81 82 I. AN INTRODUCTION TO DBT SKILLS TRAINING Behavioral Dialectical Strategies 1. Paying attention assessment Change Strategy Acceptance 2. Reflecting back Contingency Strategies Type Strategies accurately management procedures Irreverence Core Validation 3. Accurately reading Cognitive the unsaid modification Problem Communication Reciprocally procedures solving style 4. Understanding the causes Skills Consultation to Management Environmental training the patient of environment intervention procedures 5. Acknowledging the inherently valid... Exposure 6.... with equality procedures and authenticity Modularity of Modularity of Problem-Solving Validation Strategies Strategies FIGURE 5.2. Example of modularity of strategies and procedures. training procedures are part of the problem-­solving specifically in skills training, as well as some of the change strategies. Although not exhaustive, the modifications of strategies I have found useful, par- modules shown in Figure 5.2 represent treatment ticularly in a group context. strategies that skills trainers routinely use and are described in more detail later in this chapter. The focus in skills training is for the client to learn and Dialectical Strategies: put into action new skillful means of responding to Maintaining Therapeutic Balance problems in living. Although the skills taught can be divided into change skills and acceptance skills (see The dialectical focus in DBT occurs at two levels of Figure 5.3), learning and using new skills neverthe- therapeutic behavior. At the first level, a skills train- less represents a change on the part of the client. er must be alert to the dialectical balance occurring Integrative strategies outline how to handle spe- within the treatment environment. In a group set- cific problem situations that may come up during ting, each group member (including each leader) is skills training, such as problems in the therapeutic in a constant state of dialectical tension at many lev- relationship, suicidal behaviors, therapy-­destroying els and in many directions. The first set of tensions behaviors, and ancillary treatments. Some of these consists of those between each individual member strategies have already been discussed in Chapters and the group as a whole. From this perspective, the 3 and 4. A number of therapist strategies have also group has an identity of its own, and each member been translated into skills for clients and are dis- can react to the group as a whole. Thus, for example, cussed further in Chapters 6–10. All the strategies a member may be acting in dialectical tension with are discussed in detail in the main DBT text. Skills the group’s norms, its beliefs or attitudes, or its “per- trainers need to know them all in order to respond sonality.” In addition, insofar as the identity of the flexibly to new problems that arise. This chapter group as a whole is both the sum of and more than reviews the basic DBT strategies and procedures; it its parts, the identity of each individual in the group also addresses some of the problems that may arise is in some aspect defined by his or her relationship to  5. Application of Fundamental DBT Strategies in Behavioral Skills Training 83 the group. Because both the identity of the group and sessions via long-term memory and established the identity of each individual change over the skills behavioral patterns. This framework will help the training year, identification of members with the group leaders avoid the mistake of always interpret- group and the struggles that evolve with this identity ing members’ behavior from the point of view of provide a dialectical tension that can be harnessed a closed system, which assumes that all responses for the sake of therapeutic progress. are a direct reaction to events within sessions. It is A second set of tensions consists of those between far more common, however, for a group activity or each individual pair within the group—­ tensions event to precipitate the remembering of events that that can become active at any moment when two have occurred outside sessions. Clients with dis- group members interact. A drawback of allowing ordered emotion regulation are often quite unable members to interact with one another outside the to put aside cognitive processing of very stressful group is that relationships between members can events, to stop ruminating, or to focus on one thing develop outside the public arena of the group. Thus in the moment. It is also a mistake, on the other the dialectical tensions between one member and hand, for the leaders never to attribute client behav- another will often not be apparent to the leaders or ior to in-­session events. It is this dialectical tension other group members. Overlaying and interfacing between and among influential events that the lead- with these two levels, so to speak, is a third set of ers must be attuned to. dialectical tensions between each individual and his The second level of dialectical focus is on teaching or her unique environment—a context brought into and modeling dialectical thinking as a replacement the treatment situation via long-term memory. for dichotomous, either–or, black-and-white think- The group leaders must be aware of the multiple ing. It is important for both leaders and co-­leaders tensions impinging on a skills training session at to be facile with an array of dialectical techniques. any given time. Maintaining a therapeutic balance and moving the balance toward reconciliation and Specific Dialectical Strategies growth are the tasks of the skills trainers. It is essen- tial here for each trainer to remember that he or she Dialectical strategies are described in simple lan- is also a group member—and thus is also in dialecti- guage in the skills handouts on dialectics (Interper- cal tension with the group as a whole, with the other sonal Effectiveness Handouts 15 and 16), and all of leader, and with each individual member. the dialectical strategies are described in detail in Clearly, the dialectical framework that is neces- Chapter 7 of the main DBT text. Although trainers sary here is that of a dynamic, open system. The will use all of the dialectical strategies at one time or system includes not only those present, but also another, some are particularly useful in skills train- all external influences that are brought into group ing. Observe Mindfulness Describe Acceptance skills Distress Tolerance Participate Change skills Emotion Regulation Nonjudgmentally Interpersonal Effectiveness One-mindfully Effectively FIGURE 5.3. Example of modularity of DBT skills. 84 I. AN INTRODUCTION TO DBT SKILLS TRAINING The most common dialectical strategies in DBT “How can we all be right, and how can we test the are storytelling and metaphors. The teaching notes effectiveness of our strategies?” for each skill (Chapters 6–10 of this manual) pro- vide a number of examples but are by no means exhaustive. For example, at the very start of skills Typical Dialectical Tensions training, the opportunity arises to enter the paradox Feelings and Beliefs versus Wise Mind of how it can be that everyone is doing the best they can and simultaneously everyone needs to do bet- The strategy of “wise mind” is the first core mind- ter. Entering the paradox here requires the trainers fulness skill taught (see Chapter 7 of this manual) to refrain from providing rational explanations; in and should then be encouraged throughout skills order to achieve understanding and to move toward training. When a client makes a statement repre- synthesis of the polarities, each person needs to re- senting an emotional or feeling state (e.g., “I feel solve the dilemma for him- or herself. fat and unlovable”) as if the feeling state provides Playing the devil’s advocate is another key strat- information about the empirical reality (“I am fat egy. A trainer presents a propositional statement and unlovable”), it is effective at times simply to that is an extreme version of one of a client’s own question the client: “I’m not interested right now in dysfunctional beliefs, and then plays the role of what you believe or think. I am interested in what devil’s advocate to counter the client’s attempts you know to be true in your wise mind. What do to disprove the extreme statement or rule. It is an you know to be true? What does wise mind say is important strategy for helping clients let go of in- true?” The dialectical tension is between what the effective myths about emotions and about using client believes in “emotion mind” and what he or interpersonal skills. Almost any disaster or crisis she thinks to be true (“reasonable mind”); the syn- is an opportunity to practice not only particular thesis is what she knows to be true in wise mind. skills, but the strategy of making lemonade out The push toward wise mind can be easily abused, of lemons (i.e., finding the positives in a negative of course, especially when a trainer confuses wise situation). mind with what the trainer believes to be the case. As I have noted in Chapter 2 of this manual, con- This can be particularly difficult when the trainer ducting an open (rather than closed) group offers an overvalues the wisdom of his or her own knowledge opportunity to allow natural change—yet another or opinions. The value of therapeutic humility can- dialectical strategy. Dialectics are critically impor- not be overstated. When such divergences arise, the tant in the two most important characteristics of trainer’s task is to ask, “What is being left out of my skills training: assessing use of skills and teaching own position?” while simultaneously looking for a new skills. Assessing dialectically involves openness synthesis. In DBT, one of the major functions of the to being incorrect in one’s analysis and understand- consultation team is to provide a balance to the ar- ing of clients’ difficulties with skills. It is always rogance that can easily accompany a therapist’s or asking the question “What is being left out here?” trainer’s powerful position. A group setting, in particular, offers a rich envi- ronment for demonstrating the futility of approach- Willingness versus Willfulness ing problem solving with a “right versus wrong” cognitive set. No matter how brilliant a solution The tension between “willingness” and “willful- to a particular problem may be, it is always pos- ness” is an important one in skills training. Al- sible for a group member to come up with another though I discuss it much more fully in Chapter 10 strategy that may be equally effective. And every of this manual, the essential tension is between re- problem solution has its own set of limitations; that sponding to a situation in terms of what the situ- is, there is always “another side of the story.” It is ation needs (willingness) and responding in a way extremely important for the group leaders not to get that resists what a situation needs or responding in into a battle of trying to prove that the skills being terms of one’s own needs rather than those of the taught are the only right way to handle every situa- situation (willfulness). Thus willfulness encompass- tion, or even any particular situation. Although the es both trying to “fix” the situation and sitting pas- skills may be very effective for some purposes, they sively on one’s hands, refusing to respond at all. are not more “right” than other approaches. Thus Many forms of this tension can arise during skills the leaders’ task is to ask this question repeatedly: training. A key one arises in a group context when  5. Application of Fundamental DBT Strategies in Behavioral Skills Training 85 the leaders are interacting with one member or The synthesis of willfulness on each side is will- the group as a whole, and the member or group is ingness. It is critically important to remember that withdrawing and refusing to interact. The tension no matter how aversive a client’s behavior may be, is between the leaders’ attempting to influence the willfulness cannot be fought with willfulness. Thus member or group and allowing themselves to be in- it is critical that skills trainers respond to willful- fluenced by the member or group. The essential ques- ness with willingness. For example, I have often tion, framed somewhat more directly, is this: How found it useful to ask (in a light voice) a client who far should the leaders push, and how far should the appears willful, “Are you by chance feeling willful group member or the group as a whole resist? Use right now?” If the client answers yes, I ordinarily of the terms “willfulness” and “willingness” can be ask, “How long do you think you are going to be quite helpful in this dilemma. I have found myself on willful?” With or without an answer, I “allow” the many occasions discussing who is being willful with willful client to continue to be willful and ask only a client. Is it me, the client, or both of us? Of course, that he or she let me know when willingness returns. the answer to the question revolves around what is With adolescents who are willful in skills training, I needed in the situation, and it is at this point that have asked, “Hmm, are you by chance on strike?” If skill becomes important. It is also, however, a matter the answer is yes, I say “OK,” and keep on with the of perspective or dialectical focus. The group leaders rest of the group. must keep in mind the member’s or group’s needs at the moment and in the long term—­current com- Good Guy versus Bad Guy fort versus future gain—and balance these respec- tive goals. If this balance is missed, then the leaders In a group setting, keeping group members work- are in danger of being willful. It is all too easy to get ing together collaboratively is often very hard work into a power struggle with group members, in which for the leaders. Variations in individual members’ the needs of the leaders to make progress, to feel ef- moods when they arrive for a session, as well as re- fective, or to create a more comfortable atmosphere actions to in-­session events, can have a tremendous come into conflict with the needs of the members. effect on any given individual’s willingness to work The problem of willfulness versus willingness is collaboratively during a particular group meeting. nowhere more apparent than when a skills trainer It is not atypical that an entire group may be “not is juggling the needs of an individual group mem- in the mood” for working at a particular meeting. ber and those of the group as a whole. This most When this happens, the leaders must continue to commonly occurs when one member is refusing to interact with the group members in an attempt to interact; is hostile; or otherwise is behaving in a way get them working collaboratively again. However, that influences the mood, comfort, and progress of this attempt to interact with the members is often the entire group. In my experience, such a threat viewed by the members as “pushing,” and the leader to the group’s good can bring out the tendency to doing the work (usually the primary group leader) be willful in a skills trainer. Generally the tension is viewed as the “bad guy” by the group members. here is between two types of willfulness. On the one At this point it is often helpful for the co-­leader to hand, a trainer can be willful by actively control- validate the group members’ experience. As they are ling or attacking the errant member or his or her pushed by the primary leader, they often not only behavior. Because group members are often singu- retreat but become more rigid in their refusal to in- larly unskilled at coping with negative affect, when teract. Validation from the co-­leader can reduce the one member creates conflict, other group members negative affect and enhance their ability to work. may withdraw. As the mood of the group becomes When this occurs, however, the co-­leader may then increasingly tense or hopeless, the skills trainer nat- be viewed as the “good guy.” Thus the dialectical urally wants to turn it around; thus the attempt to tension builds between the leaders. This scenario control the member initiating the conflict ensues. In is closely related to the psychodynamic concept of contrast, the skills trainer can be equally willful by “splitting.” ignoring the conflict and tense mood and respond- The danger is that the leaders will allow them- ing in a passive way. Passivity in this case actually selves to become “split,” so to speak, acting as inde- masquerades as activity, since ignoring the tension is pendent units rather than a cohesive whole. This is generally manifested by the trainer’s continuing to most likely to happen if either of the leaders begins push and escalate the conflict. to see his or her position as “right” and the other 86 I. AN INTRODUCTION TO DBT SKILLS TRAINING leader’s position as “wrong.” Once this happens, the relationships as a whole that will eventually allow leaders pull away from one another and disturb the their clients to learn to do the same. As the trainers balance that might otherwise occur. This will not model balance, clients will learn to balance them- go unnoticed, because group members watch the re- selves. lationship between the leaders closely. I often refer to group skills training as a recreation of family Content versus Process dinners. Most members have many experiences of unresolved conflicts and battles occurring at family As noted previously, group process issues are not at- dinners. Group skills training is an opportunity for tended to systematically during group skills train- members to experience a wholeness in the resolution ing, except when negative process threatens to de- of conflict. The leaders’ ability to contain the dialec- stroy the group. For this to go smoothly, it is critical tic in their relationship—to stay united and whole, that skills trainers orient participants to the differ- even as they take different roles—is essential for this ence between a skills training group and a therapy learning. Of course, being the “good guy” can be process group. Those who have been in the latter quite comfortable, and being the “bad guy” can be often have difficulties with the concept of learning quite uncomfortable. Thus it takes some skillfulness skills versus discussing and working on interperson- and personal feelings of security for the primary al processes. When interpersonal conflicts arise in a leader to take the role of the “bad guy.” (I should be group, or emotions become so dysregulated that it careful to note here that it is not always the primary is difficult to make progress, the tension that imme- leader who is the “bad guy”; at times, either leader diately arises is between a decision to proceed with can take this role.) teaching content versus a decision to stop and attend Another dialectical tension that may build is that to the process in the group. between the skills training leaders and clients’ indi- Attending to process can be fraught with difficul- vidual psychotherapists. Here the skills trainers can ties, particularly when clients are highly dysregulat- either be the “good guys” or the “bad guys,” and ed. More than a few minutes of process is often more the individual therapists can play the correspond- than these clients can handle. The danger is that a ing role. In my experience, during the first year of conflict beginning in one session may not be re- a standard comprehensive DBT treatment program, solved, because clients walk out or the session ends. the skills trainers are more often the “bad guys” and When this happens and the conflict is serious, the the individual therapists are the “good guys”; how- skills leaders may need to spend time talking with ever, on occasion the roles are switched. In fact, this clients individually to help them work through the is one of the great assets of separating skills training issues. If possible, it is best to put these discussions from individual therapy in DBT: It allows a client to off until a session break, or to hold them after the have a “bad guy” and a “good guy” simultaneously. session, by phone between sessions (if the conflict Thus the client is often able to tolerate staying in is severe), or before the next session. To highlight therapy more readily. that these discussions are not individual therapy, I The function of the “good guy” is often to hold conduct them somewhere in the hallway—or, if it the client in therapy while he or she resolves con- is necessary to go into a room to talk, I keep the flicts with the “bad guy.” Many individuals with door open. On the other hand, if content alone is at- disordered emotion regulation do not have the ex- tended to without any attention to process, a group perience of staying in a painful relationship long can eventually break down. This is particularly the enough to work a conflict out and then to experi- case when the leaders have not been able to establish ence the reinforcement of conflict resolution. DBT, a norm of coming to group skills training on time, therefore, offers perhaps a unique context in which of doing homework assignments, of paying atten- this can be done. In a sense, clients always have a tion in group sessions, and of treating others with benign consultant to help them deal with conflicts respect. In these cases, holding the balance between with the other providers. The essential ingredient content and process is essential. is that whoever is the “good guy” must always be In my experience, some skills training leaders do able to hold in mind the therapeutic relationships as better with content and find it easy to ignore pro- a whole, rather than allowing them to resolve into cess, whereas other leaders do well with process and “right versus wrong” and true “good guy versus bad find it easy to ignore content. It is rare that a leader guy.” It is the skills trainers’ ability to hold these will find achieving this critical balance an easy task.  5. Application of Fundamental DBT Strategies in Behavioral Skills Training 87 Perhaps the key is recognizing that individuals with Willingness, however, requires clarity on the low distress tolerance pull toward making every skills trainers’ part. The clarity needed has to do moment they are in comfortable. Their inability to with the ultimate goals of therapy for an individual put discomfort on a shelf and attend to a task poses member (or for the group, in a group setting) and a formidable obstacle to continuing with content the means of achieving the goals. The tension that when process issues are in the foreground. We have most often exists is that between current comfort found it necessary, time and again, to forge ahead. and learning to deal with discomfort. Skills trainers Forging ahead generally requires the trainers to ig- must straddle these two aims in coming to a deci- nore some or even most of the process issues, and sion about what is the most effective response to a to respond as if clients are collaborating even when client’s assertive behavior. they are not. It is a delicate balance that can only be The task is much easier, of course, if the skills mastered with experience. trainers can see emerging client assertiveness as progress rather than as a threat. However, life be- comes much more difficult for the trainers when Following the Rules clients begin interacting as peers rather than as “cli- versus Reinforcing Assertiveness ents.” The “one up, one down” relationship that so As noted in Chapter 3 of this manual, DBT skills often exists in therapy is threatened as the clients training has a number of rules. These rules are not make progress. To the extent that the skills trainers unimportant, and some of them are unequivocal can take delight in the clients’ emerging abilities to and unbendable. On the other hand, a primary tar- outreason and outmaneuver them, therapy progress get in DBT is teaching interpersonal skills, includ- will be enhanced and not threatened. Essential in ing the ability to assert oneself. If skills trainers are a group context, of course, is respecting the other doing their job well, a tension arises over time be- group members’ point of view. It is also essential for tween maintaining the rules (regardless of clients’ the trainers to recognize when they are up against assertions and requests to the contrary) and rein- a brick wall and are not going to win their point forcing clients’ growing assertive skills by bending anyway. At these times, the willingness to bend the the rules when requested in an appropriate manner. rules and agree to a client’s assertive request can The ability to balance “giving in” and “not giving sometimes radically change the nature of the thera- in” is essential. It is here that the trainers’ attitude of peutic relationship. compassionate flexibility must be balanced with un- The use of two leaders in conducting group treat- wavering centeredness (qualities discussed in Chap- ment offers further avenues for setting up dialectic, ter 4 of the main DBT text). as noted earlier. In essence, each group leader’s style What is required is clear thinking on the part of can function as one element in the dialectical oppo- the skills trainers. Giving in for the sake of giving in sition. For example, a “good cop, bad cop” strategy, is as rigid as holding to rules for their own sake. The in which one leader focuses on content while the simple fact that a client requests that a rule be bent other focuses on process, can be used. Or one leader or broken in an appropriate manner, however, is not can help the other leader and a group member syn- sufficient for reward. Clearly, appropriate requests thesize a tension or conflict. While one leader pres- are not always met with a gracious response in the ents one side of the whole, the other leader presents real world. In fact, one of the key misconceptions the contrasting side. of many individuals I treat is that if they ask ap- propriately, the world will (or should) always give them what they need or want. Learning to deal with Core Strategies: the fact that this does not always happen is essen- Validation and Problem Solving tial for growth and is one of the goals of distress Validation tolerance training (see Chapter 10 of this manual). On the other hand, the attempt to teach this funda- The validation strategies (representing core accep- mental lesson should not be confused with arbitrary tance) are essential to DBT. As noted previously, it refusals to make exceptions when the situation re- was the necessity of combining validation—a set of quires it. Once again, the notion of willingness can acceptance strategies—with problem-­ solving and be viewed as the synthesis, and thus as the path for other change strategies that first led me to develop the trainers to follow. a “new” version of CBT. Problem solving must be