DBT Skills Training Strategies PDF

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...

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 88 I. AN INTRODUCTION TO DBT SKILLS TRAINING intertwined with validation. As in individual DBT, taught in the Interpersonal Effectiveness module. In- validation strategies are used in every skills training dividuals with high emotion dysregulation are very session in DBT. They involve a nonjudgmental atti- often exceptional in their ability to empathize with tude and a continual search for the essential validity and validate one another. They are also capable of of each client’s responses (and, in a group context, highly judgmental responses. (In some groups, this those of the group as a whole). In group settings, can become a special problem if the wind-down at both the leaders and the group as a whole function the end of session includes individual observations.) as the opposing pole to the invalidating environ- They can find it very difficult to understand and ments commonly experienced by individuals with validate emotional patterns they have not experi- disordered emotion regulation. enced, thought patterns they are not familiar with, The first general task in validating during skills and behaviors they have not exhibited. My experi- training is to help clients observe and accurately ence, however, is that group members bend over describe their own emotions, thoughts, and overt backward to validate one another, and that a greater behavior patterns. Much of DBT behavioral skills problem is for the leaders to draw out their critical training—in particular, mindfulness training—is observations that might provide valuable feedback aimed at just this. Second, skills trainers communi- to others. Peace at all costs—a typical objective in cate empathy with clients’ emotional tone, indicate some invalidating environments—should not be understanding of (though not necessarily agree- the norm in group skills training. Other clients, of ment with) their beliefs and expectancies, and/or course, grew up with the norm of no peace at any make clear observations of their behavioral action cost; once again, a dialectic emerges. patterns. In other words, the trainers observe and In group skills training sessions, validation means describe the clients’ behavior accurately. Third, and that the leaders should always point out the truth most importantly, the trainers communicate that the inherent in clients’ comments and group experi- clients’ emotional responses, beliefs/expectancies, ences, even while simultaneously demonstrating and overt behaviors are understandable and make the contradictory point of view. Conflict within the sense in the context of their lives and the current group or between an individual group member and moment. It is particularly important for the skills a leader is dealt with by validating both sides of the trainers to validate normative behaviors and those conflict and arriving at a resolution that finds the that fit the facts of the clients’ situations. In each synthesis of both points of view, rather than invali- instance, the trainers look for the nugget of gold in dating one side or the other. the cup of sand—the validity within what may oth- erwise be a very dysfunctional response. This is the A “How To” Guide for Validation reverse of the invalidating environment’s approach. The components of validation are outlined in Figure The essence of validation is this: The skills train- 5.2 and are discussed further below and in detail in ers communicate to the clients that their responses Interpersonal Effectiveness Handouts 17 and 18, as make sense and are understandable within their cur- well as Chapter 8 of the main DBT text. rent life context or situation. The trainers actively In both group and individual skills training, al- accept clients and communicate this acceptance to most constant cheerleading is necessary. The skills clients. Clients’ responses are taken seriously and trainers’ biggest problem here will probably be are not discounted or trivialized. Validation strate- maintaining the energy necessary to cajole, prod, gies require the skills trainers to search for, recog- sweet-talk, and cheer on the clients’ very slow move- nize, and reflect to the clients and/or the group as ment in adopting new, more skillful behaviors. The a whole the validity inherent in their responses to tensions between “I can’t; I won’t,” and “You can; events. With unruly children, parents have to “catch you must,” can drain even the most energetic train- them while they’re good” in order to reinforce their er. Each group leader must rely on the other to pro- behavior; similarly, skills trainers have to uncover vide fresh energy when one is losing steam or when the validity within clients’ responses, sometimes one needs to be bailed out of a willful dialogue with amplify this validity, and then reinforce it. members. Two things are important to note here. First, vali- It is equally important in group skills training to dation means the acknowledgment of that which is elicit and reinforce clients’ validation of one anoth- valid. It does not mean “making” valid. Nor does er. The ability to validate others is one of the skills it mean validating that which is invalid. The skills  5. Application of Fundamental DBT Strategies in Behavioral Skills Training 89 trainers observe, experience, and affirm, but do not “mind-read” the reasons for the clients’ behavior create validity. Second, “valid” and “scientific” are and figure out how the clients feel and what they not synonyms. Science may be one way to deter- are wishing for, thinking, or doing, just by knowing mine what is valid, logical, sound in principle, and/ what has happened to the clients. The skills train- or supported by generally accepted authority. How- ers can make the link between precipitating events ever, an authentic experience or apprehension of pri- and behaviors without being given any information vate events is also a basis for claiming validity—at about the behaviors themselves. The trainers can least, when it is similar to the experiences of others also articulate emotions and meanings the clients or when it is in accord with other, more observable have not expressed. Level 3 validation is most im- events. portant in the review of homework and in respond- Validation can be considered at any one of six ing to clients’ difficulties in learning, accepting, or levels. Each level is correspondingly more complete practicing new skills. than the previous one, and each level depends on „„ At Level 4, behavior is validated in terms of the previous levels. Taken as a whole they are defini- its causes. Validation here is based on the notion tional of DBT and are required in every interaction that all behavior is caused by events occurring in with the client. I have described these levels most time; thus, in principle, it is understandable. The fully in a 1997 publication.1 skills trainers validate (this validation is not to be confused with “approval” or “excusing”) the cli- „„ At Level 1 of validation, the skills trainers lis- ents’ behavior by showing that it is caused by past ten to and observe what clients are saying, feeling, events. Even though information may not be avail- and doing. They also make corresponding active ef- able to determine all the relevant causes, the clients’ forts to understand what is being said and observed. feelings, thoughts, and actions make perfect sense The essence of this step is that both the skills leader in the context of the clients’ current experiences, and co-­leader stay awake and interested in clients, physiology, and lives to date. At a minimum, what paying attention to what they say and do in the cur- “is” can always be justified in terms of sufficient rent moment. The trainers notice the nuances of causes; that is, what is “should be,” in that what- response in the interaction. Validation at Level 1 ever was necessary for it to occur had to have hap- communicates that the client per se, as well as the pened. client’s presence, words, and responses in the ses- „„ At Level 5, skills trainers validate in terms of sion, have “such force as to compel serious attention present context or normative functioning. Skills and [usually] acceptance.”2 Although both trainers trainers communicate that behavior is justifiable, are charged with Level 1 validation, paying atten- reasonable, well grounded, meaningful, and/or effi- tion to nuances of responses across the entire group cacious in terms of current events, normative biolog- is a special responsibility of the co-­leader, as noted ical functioning, and/or clients’ ultimate life goals. in Chapter 2. The skills trainers look for and reflect the wisdom „„ At Level 2 of validation, the skills trainers ac- or validity of clients’ responses (and often those of curately reflect back to the clients the clients’ own the group as a whole), and communicate that the re- feelings, thoughts, assumptions, and behaviors. sponses are understandable. The skills trainers find The skills trainers convey an understanding of the the relevant facts in the current environment that client by hearing what the clients have said, and see- support clients’ behaviors. The clients’ dysfunction ing what the clients do and how they respond. Vali- does not blind the skills trainers to those aspects of dation at Level 2 sanctions, empowers, or authenti- response patterns that may be either reasonable or cates that each individual is who he or she actually appropriate to the context. Thus the skills trainers is. At Level 2, the skills trainers are always checking search the clients’ responses for their inherent rea- to be sure that their reflections are accurate, and sonableness (as well as commenting on the inherent are always willing to let go of their previous under- dysfunction of various aspects of these responses, if standing in favor of a new understanding. necessary). „„ At Level 3 of validation, the skills trainers ar- „„ Level 6 of validation requires radical genuine- ticulate the unverbalized. The skills trainers com- ness on the part of the skills trainers. The task is municate understanding of aspects of the clients’ ex- to recognize each person as he or she is, seeing and perience and response to events that have not been responding to the strengths and capacities of the cli- communicated directly by the clients. The trainers ent, while keeping a firm empathic understanding 90 I. AN INTRODUCTION TO DBT SKILLS TRAINING of his or her actual difficulties and incapacities. The Problem Solving skills trainers believe in each client and his or her A number of the core problem-­ solving strategies capacity to change and move toward ultimate life have been discussed in Chapter 4 (behavioral analy- goals, just as they may believe in a friend or fam- sis, insight, didactic strategies, solution analysis, ily member. The trainers respond to the client as a and orienting/commitment strategies). In this sec- person of equal status, due equal respect. Valida- tion, I review several additional and important tion at the highest level is the validation of the indi- problem-­ solving procedures as outlined in Figure vidual “as is.” The skills trainers see more than the 5.2: contingency management, exposure-based pro- role—more than a “client” or a “disorder.” Level cedures, and cognitive restructuring. These proce- 6 validation is the opposite of treating a client in dures are each aimed at change and are basic com- a condescending manner or as overly fragile. It is ponents of all major CBT approaches. It’s important responding to the individual as capable of effective not only for therapists to be adept at using these and reasonable behavior rather than assuming that procedures, but also for clients to know them; ele- he or she is an invalid. Whereas Levels 1–5 represent ments of each procedure have been translated into sequential steps in validation of a kind, Level 6 rep- DBT skills. Contingency management procedures resents change in both level and kind. are taught in the Interpersonal Effectiveness mod- ule (Chapter 8, Section XVII; see also Interpersonal Two other forms of validation should also be Effectiveness Handouts 20–22). The skill of oppo- mentioned here: site action (Emotion Regulation Handouts 9–11) is based on exposure procedures long known to be ef- „„ Cheerleading strategies constitute a further fective treatments for anxiety and phobias. In DBT, form of validation and are the principal strategies these principles have been expanded to apply to all for combating active passivity and tendencies to- problem emotions. The skill of checking the facts ward hopelessness in many clients with serious emo- (Emotion Regulation Handouts 8–8a) is a transla- tion dysregulation. In cheerleading, skills trainers tion of cognitive restructuring into a skill. These communicate the belief that clients are doing their procedures are also covered in Chapter 10 of the best and validate clients’ ability to eventually over- main DBT text. come their difficulties (a type of validation that, if not handled carefully, can simultaneously invalidate clients’ perceptions of their helplessness). In addi- Contingency Management Procedures tion, skills trainers express a belief in the therapy re- lationship, offer reassurance, and highlight any evi- Every response within an interpersonal interaction dence of improvement. Within DBT, cheerleading is is potentially a reinforcement, a punishment, or a used in every therapeutic interaction. Although ac- withholding or removal of reinforcement. “Contin- tive cheerleading should be reduced as clients learn gency management” is the provision of consequen­ to trust and to validate themselves, cheerleading ces for specific behaviors, aimed at increasing or strategies always remain an essential ingredient of a maintaining behaviors that are wanted and decreas- strong therapeutic alliance. ing behaviors that are not wanted. Although natural „„ Functional validation is yet another form of consequences are preferred (see below), they often validation that is used regularly in DBT. It is a form do not occur frequently or immediately enough to of nonverbal or behavioral validation that, at times, be effective in changing client behavior patterns. may be more effective than verbal validation. For Thus contingency management requires skills train- example, if a skills trainer drops a 50-pound block ers to organize their behavior strategically, so that on the client’s foot, it would be considered invalidat- client behaviors that represent progress are rein- ing if the trainer’s response is to do nothing except forced, while unskillful or maladaptive behaviors say, “Wow, I can see that really hurts! You must be are extinguished or punished. in a lot of pain.” Functional validation would entail Orientation to contingency management in skills the trainer’s removing the block from the client’s training starts with the first session. When the rules foot. of DBT skills training are introduced in the first ori- entation session, the major therapeutic contingen- See Chapter 8 of the main DBT text for more on cies are discussed. However, only two of the rules validation. involve clear contingencies: Missing 4 consecutive  5. Application of Fundamental DBT Strategies in Behavioral Skills Training 91 weeks of scheduled skills training sessions, or not It is important to note that praise of skills use may meeting with one’s individual DBT therapist for or may not reinforce clients’ skillful behaviors. For four consecutive scheduled sessions (if a client is in example, if an individual’s history involves many in- standard DBT) or as required by the specific skills stances in which praise and acknowledgment of skill program (if a client is in a non-DBT treatment), will and strength have led to an absence of further help result in termination of therapy. There are no clearly and/or higher expectations, praise may be aversive stated contingencies for violation of the other rules. instead of rewarding. It is not a good idea, however, In my experience, it is never a good idea to tell cli- to stop praising skillful behaviors altogether, for ents that they will be terminated from skills train- two reasons. First, a client can interpret the absence ing if they break the other rules. However, there are of praise as never being able to do anything right— contingent consequences. The main ones are trainer in other words, as implied criticism. Second, praise and/or member disapproval, leader and group atten- in most settings is meant as a reinforcer, and it is im- tion to the rule breaking, and more interpersonal portant for praise to become a reinforcer for clients. distance. So what is the synthesis? The best strategy is not to The basic idea in contingency management is go overboard with excessive praise, but to give clear that a client’s adaptive functional behavior results feedback about skillful behavior (i.e., to comment in reinforcement, whereas negative maladaptive be- that the behavior is skilled if it is, and constitutes havior results in either aversive consequences or no progress if it does), and when necessary to follow discernible consequences that could reinforce the this immediately with recognition that this does not behavior. A “reinforcer,” by definition, is any be- mean the client can solve all of his or her problems havioral consequence that increases the probability or has no more problems to be solved. In this way, of the behavior’s occurring again. “Extinction” is the praise is freed from the expectancy that compe- reducing the probability of a behavior’s occurring tence will result in loss of any further help. It is also by removing the behavioral reinforcer(s). “Punish- important to remember to balance praising effective ment” is any behavioral consequence that decreases use of skills with praising effort even when it is not the probability of the behavior’s occurring again. effective. Praise of effort is particularly important when new behaviors are being shaped. Use (and mis- use) of praise as a reinforcer is discussed in more Applying Reinforcing Contingencies detail in Chapter 10 of the main DBT text. As noted, any consequence that increases the prob- ability of a behavior is a reinforcer. The most im- Natural Reinforcers portant point is not to assume that any particular response to a client’s behavior is a positive rein- As far as possible, skills trainers should try to pro- forcer without checking. For example, in our clinic, vide natural reinforcers for clients’ adaptive behav- not only do we use stickers as reinforcers for doing ior. “Natural reinforcers” are consequences that skills homework and for coming to skills training clients can expect in everyday life. Thus, if clients on time; we also let participants tell us what stickers are taught assertion skills, and trainers never re- they want, and we pay close attention to whether ward assertive behaviors by giving clients what they using stickers is working to increase and maintain request, then it is unreasonable to expect those be- the targeted behaviors. Ordering pizza for the group haviors to continue. Similarly, if clients’ attempts if all members were present, for example, did not at regulating intense anxiety precipitated by being work in our substance dependence program. As I asked to talk in skills training sessions are met with have mentioned in Chapter 4, when a client said in trainers’ making them talk even longer, then it is one of my groups that she did not think it was fair unreasonable to expect the clients to continue regu- that I gave out “12,000 gold stars” to people outside lating their anxiety. If clients improve their toler- of group (as she had heard), I immediately started ance of aversive events during sessions, and this is giving out “10,000–13,000 gold stars” for any skill- followed by the trainers’ allowing sessions to be- ful behavior that appeared to be particularly diffi- come more aversive, then it is unreasonable to ex- cult for participants to do. Because the gold stars pect further distress tolerance. The point is that as were completely imaginary, it had not occurred to clients begin to apply the skills being taught, skills me that they would work with skills participants. trainers must be careful to respond in a manner Work, however, they did. that will reinforce such improvement. Although 92 I. AN INTRODUCTION TO DBT SKILLS TRAINING shaping principles require the trainers eventually to ment modalities, as well as the systematic and tena- “up the ante,” so to speak, by requiring even more cious withdrawal of usual reinforcers (extinction). skillful behavior, these increases in demands must Three guidelines are important in using aversive be kept gradual. Otherwise, clients will always feel consequences. First, punishment should “fit the that they cannot do enough to please the trainers crime,” and a client should have some way of ter- or get their needs met. It can also be useful to pair minating its application. For example, a detailed natural reinforcement with praise. analysis when skills practice assignments are not done is ordinarily aversive for most clients. Once it has been completed, however, a client’s ability to Shaping pursue other topics should be restored without fur- In “shaping,” gradual approximations to the target ther comment about the client’s not completing the behavior are reinforced. Shaping requires a skills week’s assignment. Second, it is crucial that skills trainer to break the desired behavior down into trainers use punishment with great care, in low small steps and to reinforce each of these steps se- doses, and very briefly, and that a positive interper- quentially. It has to do with what behaviors a train- sonal atmosphere be restored following any client er expects from clients and is willing to reinforce. improvement. If a client is banging on the table, but Trying to extract an adaptive behavior from clients stops when a firm request is made to “cut it out,” without reinforcing small steps on the way to the a warm interaction with the client should follow. goal behavior usually does not work. Without shap- Third, punishment should be just strong enough to ing, both skills trainers and clients would become so work. Although the ultimate punishment is termina- frustrated and distressed that skills training could tion of skills training, a preferable fallback strategy not proceed. Inevitably, individuals with pervasive for egregious behavior that threatens to destroy the and severe disordered emotion regulation have no group is putting clients on “vacations from train- self-­ shaping skills. Unreasonable expectations for ing.” This approach is considered when a situation immediate perfection (by the clients, their family is so serious that it is impossible to carry on effec- members, or their therapists) can interfere with their tive group skills training, and all other contingen- ability to learn the skills gradually. Thus it is crucial cies and interventions have failed. Examples of such that skills trainers continually model shaping prin- instances might include property destruction during ciples. Not only should they be discussed openly group sessions, stealing important property of oth- and explained, but trainers’ expectations of clients ers from the clinic and refusing to return it, con- should also follow shaping principles. What group tinued selling of drugs on the clinic’s front porch, leaders sometimes forget, however, is that these putting confidential information obtained in group same principles apply to the entire group. In my ex- sessions on Facebook, buying guns for other group perience, one of the greatest difficulties in conduct- members to commit suicide with, or threatening a ing DBT group skills training is that skills trainers’ skills trainer in front of his or her children. It does expectations for the group as a whole are often far not include all the very irritating and often dysfunc- higher than the group can deliver. tional emotional behaviors that many clients engage in. Learning how to tolerate irritation is one of the important goals of skills training. It can be equally Extinction and Punishment important for skills trainers to learn it. When utiliz- As important as reinforcement is the withholding of ing the vacation strategy, the trainers clearly iden- reinforcement for behaviors targeted for extinction. tify what specific new behaviors are required, what In theory, this may seem obvious, but in practice, it behaviors have to be changed, and what conditions can be quite difficult. The problematic behaviors of must be met for the client to return. The trainers emotionally dysregulated clients are often quite ef- maintain intermittent contact by phone or letter, fective in obtaining reinforcing outcomes or in stop- and provide a referral or backup while the client is ping painful events. Indeed, the very behaviors tar- on vacation. (In colloquial terms, the trainers kick geted for extinction have often been intermittently the client out, then pine for his or her return.) reinforced by mental health professionals, family Generally, aversive procedures should be used members, and friends. Contingency management at when a client is avoiding difficult activities such as times requires the use of aversive consequences simi- coming to skills training sessions, doing homework, lar to “setting limits” (punishment) in other treat- practicing in sessions, or engaging in active prob-  5. Application of Fundamental DBT Strategies in Behavioral Skills Training 93 lem solving. In these cases, it is essential to inter- inforcement for others’ leaving. However, leaving vene immediately and push clients, instead of ignor- (and thus avoiding skills training) should not be ing them and allowing the avoidance to continue. reinforced unchecked. Thus, if the client is in indi- In other words, the avoidance response must be vidual therapy, a trainer should alert the therapist, short-­circuited. The idea is to make the immediate so that the behavior can be dealt with in individual consequences of avoiding more aversive than those therapy as an instance of therapy-­interfering behav- of not avoiding. When clients miss a session, for ex- ior, or the precipitous leaving can be discussed in the ample, our policy is to call them immediately (using next session. If the client is not in individual therapy, an unknown phone number if necessary) and try to one of the skills trainers should discuss the problem cheerlead them into coming to the session. During with the client before, after, or during a break in a such calls, skills trainers use various strategies (e.g., subsequent session. the DEAR MAN, GIVE skills, including broken re- It is very important to remember to soothe clients cord, easy manner, and negotiating) taught to clients whose behavior is on an extinction schedule and in the Interpersonal Effectiveness module. (I usually those who are receiving aversive consequences. (In have a bus schedule handy when I call.) An excep- my experience, the ability to put a client’s behav- tion to this policy, discussed later, is made when ior on an extinction schedule and simultaneously calling reinforces missing sessions. soothe the person is one of the hardest tasks for new Another common pattern in a group context is for skills trainers to learn.) In each case, the behavior is a member who did not do any homework practice to what is being punished, not the person. Especially try to avoid discussing it in the session. If the group in group skills training, leaders need to develop the leaders skip over that member and go on to the next ability to ignore many behaviors and to come back person, then the avoidance has worked. The best to the members with a soothing comment after the strategy, discussed in detail in Chapter 4, is to move behaviors stop. Or, even while the dysfunctional be- immediately, in a nonjudgmental and warm fashion, haviors are going on, leaders can soothe members to analyze not doing the homework. If the member while at the same time insisting that they practice still refuses after some pushing, a leader might move their skills anyway. To a member crying about a re- toward analyzing why he or she doesn’t want to lationship breakup, a leader might say something to talk—or, if this is too aversive, it can be discussed this effect: “I know this is really difficult for you, privately during a break. The point is that avoidance but try your best to distract yourself from your should not be rewarded. troubles. Be mindful to the task, and tell me about Positive maladaptive behaviors (e.g., attempts to your efforts to practice your skills this week.” After get attention, sobbing, hostile behavior, attempts to listening to a few other group members, the leader discuss weekly life crises) should be put on an ex- might go back to this member and ask briefly but tinction schedule. A skills trainer ignores the client’s warmly, “How are you doing with your attempt to maladaptive behaviors and continues to interact be mindful to group?... Keep trying.” with the client as if he or she is not producing such behaviors. Or, if the behaviors cannot be ignored, Observing Limits the trainer can make a brief comment suggesting that the client cope by using some of the skills being “Observing limits” constitutes a special case of con- taught in the current (or a past) skills module. Thus tingency management involving the application of a client who begins crying can be encouraged to problem-­solving strategies to client behaviors that practice distress tolerance or mindfulness skills. If threaten or cross a trainer’s personal limits. Such a client is storming out of the room, a trainer can behaviors interfere with the trainer’s ability or will- suggest calmly the use of emotion regulation skills; ingness to conduct the therapy. Trainers must take once calm, the client can come back into the ses- responsibility for monitoring their own personal sion. With few exceptions (e.g., the skills trainers limits and for clearly communicating them to cli- have clear reasons to believe that a client is leaving ents. Trainers who do not do this eventually burn to commit suicide, or the client is brand-new and is out, terminate therapy, or otherwise harm their cli- clearly overwhelmed), skills trainers should not rou- ents. DBT favors natural over arbitrary limits. Thus tinely follow clients when they leave skills training limits vary among therapists, over time, and over sessions precipitously. Even if it would not reinforce circumstances. Limits should also be presented as these clients’ leaving, it might serve as vicarious re- for the good of trainers, not for the good of clients. 94 I. AN INTRODUCTION TO DBT SKILLS TRAINING What the clients are arguing is in their best interests to the cue that precedes a problem behavior must may not ultimately be good for their skills trainers. be nonreinforced. For example, if a client is fearful For example, I am very easily distracted when that admitting to not doing the skills homework will teaching new skills. I have stopped many skills lead to his or her being rejected and starts coming training sessions to ask various members to stop late after skills review, the skills trainers must not squeaking a chair, throwing popcorn, or talking to reinforce the client’s shame by addressing the ab- their neighbors. When one client said, “Marsha, you sence of skills practice in a judgmental voice tone or are so easily distracted!”, I said, “Yes, I am, so cut it otherwise communicate rejection. Second, clients’ out, please.” When clients are repeatedly late, I may avoidance of topics, procedures, and process discus- point out how demoralized I am that they have not sions (when process is the focus) is almost always figured out how to get there on time. After one cli- blocked. Third, clients are instructed over and over ent said, “Marsha, you are always demoralized,” I about the value of exposure. After several months in replied, “And I would stop being demoralized if you well-run DBT skills training, every client should be would get here on time.” able to give a very good rationale for why and when An important limit in standard DBT is that a avoidance makes things worse and why, and when group skills trainer takes calls when a client wants exposure improves them. Thus, when clients employ to find out what the homework was or to say that exposure to difficult tasks or feared situations dur- the client will not attend or will be late, but the ing homework practice, the skills trainers should trainer does not take coaching calls. The individual note and reinforce it. therapist takes these calls. In our multifamily skills groups, however, a skills leader takes coaching calls from a parent (and the adolescent’s therapist takes Cognitive Modification Procedures calls from the adolescent). Otherwise, as noted Cognitive Restructuring above, limits vary among providers, over time, and over circumstances, and often the DBT team may There are a number of structured exercises through- have to help skills trainers expand their limits. See out the skills training program for helping clients Chapter 10 of the main DBT text for more on ob- check the facts of a situation (see this manual’s serving limits. Chapter 9, Section VIII, and Emotion Regulation Handout 8 for this skill) and modify dysfunctional assumptions and beliefs. The mindfulness skills of Exposure-Based Procedures describing and being nonjudgmental focus intensely Structured exposure procedures, (e.g., prolonged on teaching clients how to describe what is observed, exposure for PTSD), are not used in DBT skills and how to tell the difference among observing an training. DBT skills training, however, can be effec- event in the environment, a thought about the event, tively combined with exposure-based protocols, and and an emotion about the event (see this manual’s many principles of exposure are woven throughout Chapter 7, Sections V and VII, and Mindfulness DBT skills. For example, as noted earlier, Opposite Handouts 4 and 5 for these skills). However, formal Action is a variation on exposure treatments. Oth- cognitive restructuring plays a much smaller role ers that also elicit exposure include: Mindfulness of in DBT than in other forms of CBT, and cognitive current emotions; observing sensations; participat- techniques play only a small role in DBT treatment ing; the distress tolerance skills of paired muscle of disordered emotion regulation in particular. This relaxation, body scan meditation, improving the topic is discussed extensively in Chapters 8 and 11 moment (which is opposite action for many), radical of the main DBT text. acceptance, and mindfulness of current thoughts; and the emotion regulation skills of the sleep hygiene Contingency Clarification protocol and mindfulness of current emotions. DBT skills in these cases can help clients cope with urges The task in contingency clarification is to help cli- to use dysfunctional means to end emotion pain and ents clarify the “if–then” contingency relationships regulate and reduce the anger, shame, or humilia- in their lives and in the learning of skills. Contingen- tion that victims of trauma often experience. Less cy clarification can be distinguished from the didac- structured exposure-based procedures, however, are tic strategies. The didactic strategies stress general consistently used in skills training. First, exposure contingency rules that hold for all or most people;  5. Application of Fundamental DBT Strategies in Behavioral Skills Training 95 contingency clarification always looks for the con- ond, “irreverent communication,” is quite similar to tingencies operating in an individual client’s life. It the style advocated by Carl Whitaker in his writ- is looking for the pros and cons of one set of behav- ings on strategic therapy. 3 Reciprocal communica- iors versus another set of behaviors. It is important tion strategies are designed to reduce a perceived for everyone to access pros and cons when deciding power differential by making the therapist more what to do in a situation, and this is why there is vulnerable to the client. In addition, they serve as a emphasis on pros and cons at the start of every skills model for appropriate but equal interactions within module. In skills training, it is important to discuss an important interpersonal relationship. Irreverent the pros and cons of learning and practicing each communication is usually riskier than reciprocity; new skill, and to analyze what happens when dys- however, it can facilitate problem solving or pro- functional behaviors are replaced with new skills. duce a breakthrough after long periods when prog- The idea here is to help clients learn to better ob- ress has seemed thwarted. To be used effectively, serve the contingent relationships occurring in their irreverent communication must balance reciprocal everyday lives. Individuals with disordered emo- communication, and the two must be woven into a tion regulation often have great difficulty observ- single stylistic fabric. Without such balancing, nei- ing these natural contingencies. When it comes to ther strategy represents DBT. I discuss stylistic strat- observing the effects of using new behavioral skills, egies briefly below; a fuller discussion is provided in they may miss the benefits. One of the skills trainers’ Chapter 12 of the main DBT text. tasks is to demonstrate to clients that the contingen- cies formerly favoring dysfunctional behaviors are Reciprocal Communication Strategies not currently operating. Homework practice always includes trying a new Responsiveness, self-­disclosure, warm engagement, skill and observing its outcome. The idea is not to and genuineness are the basic guidelines of recip- prove preconceived beliefs of the skills trainers or of rocal communication. Reciprocal communication the clients about contingent relationships, but rather is a friendly, affectionate style reflecting warmth to explore the actual contingent relationships exist- and engagement in the therapeutic interaction. Self-­ ing in the clients’ everyday lives. It will often become involving self-­disclosure in individual therapy con- clear in the process that the contingencies, or rules, sists of a therapist’s immediate, personal reactions for one person may not apply to another. Further- to a client and his or her behavior. Reciprocal com- more, rules that operate in one context may not op- munication in the context of skills training requires erate in another situation for the very same person. that trainers make themselves vulnerable to their Figuring out the rules of the game, so to speak, is clients and express this vulnerability in a manner intimately related to the behavioral skill of being ef- that can be heard and understood by the clients. As fective or focusing on what works—one of the core always, there is a question of balance here, and the mindfulness skills. Doing what works means engag- fulcrum on which this balance is based is the wel- ing in behaviors where contingent outcomes are the fare of the clients. Thus reciprocity is in the service desired outcomes. This approach is often a new one of the clients, not for the benefit of the skills training for individuals with emotion dysregulation, since leaders. Leaders’ expressions of vulnerability in ses- they are more experienced at looking at behaviors sions not only address the power imbalance that all in moral terms of “right” or “wrong” rather than clients experience, but also can serve as important in terms of outcomes or consequences. Contingency modeling events. Such expressions can teach clients clarification strategies are a step in moving these in- how to draw the line between privacy and sharing, dividuals toward more effective behavior. how to experience vulnerable states without shame, and how to cope with their own limitations. In ad- dition, they provide glimpses into the world of so-­ Stylistic Strategies called “normal” people, thus normalizing vulner- ability and life with limitations. DBT balances two quite different styles of com- One of the easiest ways to use reciprocal commu- munication that refer to how the therapist executes nication in skills training is for the skills trainers to other treatment strategies. The first, “reciprocal share their own experiences in using the skills being communication,” is similar to the communication taught. In my experience, one of the benefits of lead- style advocated in client-­centered therapy. The sec- ing skill groups is that it gives me an opportunity to 96 I. AN INTRODUCTION TO DBT SKILLS TRAINING keep working on improving my own skills. If group ally experience the very same problem. Nonetheless, leaders can share their own attempts (and especially sharing the difficulty does not make it go away. It their failures) with drama and humor, so much the can also be very difficult to respond in a manner better. Sometimes the trick is for the leaders to label appropriate to each member, when members are in their own experiences as relevant to the skills the many different places (psychologically speaking) at group is attempting to learn. For example, when I once. The time it takes to find out where even one am teaching how to say no to unwanted requests, member is may preclude efforts to explore the cur- I almost always discuss my own difficulties in say- rent psychological state of other members. And, to ing no to group members’ pressures to get me to do the extent that group leaders attend to such within-­ things I don’t think are therapeutic. Since resisting session process issues, they are veering away from their intense attempts at persuasion usually requires the goals of skills training anyway. By contrast, an me to use all of my own skills, the example covers individual skills trainer can titrate responses to fit quite a bit of the material we teach in skills training. the individual client; timing and attention to various By now, all of my skills groups know about my ef- topics can be geared to the state of the one person at forts to deal with my unreasonable fear of heights hand. In group sessions, it is very difficult to strike when I go hiking (focusing on one thing in the mo- a response that meets each member’s needs. Thus it ment, distraction, self-­ encouragement); with back is often much more difficult to move the group for- pain on meditation retreats (focusing on one thing, ward (or anywhere but down, it often seems). This radical acceptance); with my sudden fear of tunnels frustration may act to make group leaders want to (opposite action, coping ahead with various severi- pull away and close up, or, at other times, to pull ties of earthquakes); with trying to find my way after close enough to attack. Either way, the frustration getting lost while driving in Israel (radical accep- reduces the experience of warmth and engagement. tance [after hours of nonacceptance] that a road that In such a stressful atmosphere, it is sometimes dif- ended at the edge of a cliff the first time would not ficult to relax. And it is difficult for leaders to be be the correct road out the next time, even if it was responsive when they are not relaxed. the only road going the right direction); and with Great care must be taken to observe the effects other assorted life dilemmas I encounter from week of self-­disclosure on group members. To a certain to week. Co-­leaders of mine have discussed their extent, their ability to accept such a stance is vari- troubles in learning to meditate, difficulties with able. In a group setting, however, individual differ- asking for things, problems in coping with bosses ences may be harder to detect than in the individual and professors, the process of mourning losses, and setting, where the focus is always on the individual so on. The point is that sharing one’s own use of client. Difficulties are easy to camouflage and easy skills being taught can provide valuable modeling to overlook. It is reasonably safe to say, however, both in how to apply skills and in how to respond that all members will have difficulties with the lead- to one’s own vulnerability in a nonjudgmental fash- ers’ expressing their frustration and/or anger with ion. The use of self-­disclosure is an important part the group; thus extraordinary care must be taken in of DBT. In skills training, modeling uses of skills doing so. and ways of coping with adversity is the most fre- quent form of self-­disclosure. The primary rule is Irreverent Communication Strategies that disclosure must be in the interest of the clients, not the interest of the skills trainers. That said, most Irreverent communication is used to push a client clients love hearing good stories from the leaders. “off balance,” get the client’s attention, present an My clients often say when I ask them if they have alternative viewpoint, or shift the client’s affective already heard a specific story, “Yes, we have, but tell response. It is a highly useful strategy when the cli- us again, Marsha.” The good news here is that, like ent is immovable, or when therapist and client are a parent telling bedtime stories, a leader can often “stuck.” It has an “offbeat” flavor and uses logic to tell a good story over and over. weave a web the client cannot escape. Although it is Reciprocal communication can be difficult to responsive to the client, irreverent communication practice in a group setting as opposed to a one-to- is almost never the response the client expects. An one setting. It can feel like many against one or two. important value of irreverence is that unexpected This difficulty, of course, should give group lead- information is more deeply processed cognitively ers more empathy for the group members, who usu- than expected information is.4, 5 For irreverence to  5. Application of Fundamental DBT Strategies in Behavioral Skills Training 97 be effective, it must both be genuine (vs. sarcastic or in a humorous fashion or viewed as a fabulous op- judgmental) and come from a place of compassion portunity for skills practice (turning the “lemon” and warmth toward the client. Otherwise, the client of problem behavior into lemonade). Behaviors or may become even more rigid. When using irrever- communications may be responded to in a blunt, ence, a therapist or trainer highlights some unin- confrontational style. The aim of irreverence is to tended aspect of the client’s communication or “re- jolt the individual client, or the group as a whole, frames” it in an unorthodox manner. For example, into seeing things from a new, more enlightened if the client storms out of skills training saying, “I perspective. Irreverent communication should help am going to kill myself,” the skills trainer might say clients to make the transition from seeing their own when catching up with the client, “I thought you dysfunctional behavior as a cause of shame and agreed not to drop out of skills training.” Irreverent scorn to seeing it as inconsequential and even funny communication has a matter-of-fact, almost dead- and humorous. To do this, a skills trainer can only pan style that is in sharp contrast to the warm re- be a half step ahead of clients; timing is of the es- sponsiveness of reciprocal communication. Humor, sence. An irreverent attitude is not an insensitive at- a certain naiveté, and guilelessness are also charac- titude; nor is it an excuse for hostile or demeaning teristic of the style. A confrontational tone can be behavior. A group leader always takes suffering seri- irreverent as well, by communicating “bullshit” to ously, albeit matter-of-­factly, calmly, and sometimes responses other than the targeted adaptive response. with humor. For example, the skills trainer might say, “Are you out of your mind?” or “You weren’t for a minute ac- tually believing I would think that was a good idea, Case Management Strategies were you?” The irreverent skills trainer also calls the Consultation-to-the-­Client Strategies client’s bluff. For the client who says, “I’m quitting therapy,” the skills trainer might respond, “Would In general, DBT requires a skills trainer to play the you like a referral?” The trick here is to time the role of a consultant to the client rather than that of bluff carefully, with the simultaneous provision of a consultant to other people in the client’s social or a safety net; it is important to leave the client a way health care network, including other therapists the out. client may have. DBT assumes that the client is ca- Irreverence has to be used very carefully in group pable of mediating between various therapists and skills training, although it can be used quite liberally health care providers. Thus the skills trainer does when skills training is conducted individually. This not play a parental role, and does not assume that is because irreverence requires a skills trainer to ob- clients are unable to communicate in a straightfor- serve very closely its immediate effects and move to ward manner with those in their own treatment net- repair any damage as quickly as possible. It is very work. When safety is an immediate issue, or it is difficult to be that astute and attentive to each indi- very obvious that a client cannot or will not serve as vidual in a group setting. The person a group leader his or her own intermediary, the skills trainer should is talking to may be very receptive to an irreverent move from the “consultation-to-the-­client” strate- statement, but another group member, listening in, gies to the “environmental intervention” strategies may be horrified. Once leaders get to know their (see below). The rationale, strategies, and rules for clients fairly well, they can be more comfortable when to use which of these two groups of strategies using irreverence. As noted above, specific examples are clearly laid out in Chapter 13 of the main DBT and the rationale for irreverent communication (as text. The consultation strategies are quite different well as reciprocal communication) are discussed in from how providers may have learned to relate to Chapter 12 of the main DBT text. other professionals treating their clients. The main place for irreverence, in a group con- The one exception to these rules occurs when text, is usually in the individual work with each cli- the skills trainers and a client’s individual therapist ent during the first hour of a session (the homework are all in a DBT program and consult weekly in the practice-­sharing component). In irreverence, prob- therapist consultation team. The role of the skills lematic behavior is reacted to as if it were normal, trainers in these consultations is to give the individ- and functional adaptive behavior is reacted to with ual DBT therapist information about how the client enthusiasm, vigor, and positive emotionality. Dys- is doing in skills training; they alert the therapist to functional plans or actions may be overreacted to problems that may need work in individual psycho-