DBT Skills Training PDF
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University of Bridgeport
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This document provides detailed information on the application of fundamental DBT (Dialectical Behavior Therapy) strategies within behavioral skills training. It elaborates on strategies such as irreverence, and addresses case management strategies, including consultation-to-the-client strategies.
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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”...
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- 98 I. AN INTRODUCTION TO DBT SKILLS TRAINING therapy, and share insights that are being given in the same manner that any other interpersonal prob- the skills training sessions. lem is dealt with. These consultations are limited to sharing of in- formation and joint treatment planning. It must, Environmental Intervention Strategies of course, be clear to the clients from the very be- ginning that they are being treated by a team of Strategies for intervening directly in the client’s en- therapists who will coordinate therapy at every op- vironment are rarely used by skills trainers. Clients portunity. The interaction of the two therapy mo- will often want much more environmental interven- dalities is stressed by both the individual therapist tion from skills trainers than the trainers should be and the skills trainers. DBT skills trainers, however, willing to give. One example (which occurs frequent- do not serve as intermediaries for individual clients ly with highly suicidal clients) has to do with getting with their individual therapists. If clients are having a pass from an inpatient unit to come to a session. problems with their individual therapists, the skills It can often be difficult for a client to talk a hospital trainers usually consult with clients on how they into giving such a pass. The client may then want a might address these problems with their individual skills trainer to call the hospital on his or her behalf. therapists. Generally, the task of the skills trainers The trainer’s first response should be to emphasize is to help clients use the skills they are learning to that it is the client’s responsibility to behave in such work on the problem. a way that inpatient treatment personnel will want If a client is in individual therapy that is inde- to allow him or her to leave the hospital on a pass pendent of the DBT program (i.e., individual work for skills training. My one concession to the politics with another therapist in a different treatment set- of inpatient hospitalization is that if it appears abso- ting), the consultation-to-the-client approach may lutely necessary, I will call the inpatient personnel to involve some contact with the individual therapist. let them know that I do indeed expect inpatients to These consultations ordinarily should be conducted get themselves out on a pass to come to skills train- with the client present. The material taught in skills ing sessions. I do not, however, try to convince them training can and usually should be shared with the to let a particular client out. Over and over in skills individual psychotherapist. The skills trainers’ task training sessions, trainers must stress that their job in this case is to help the client do this effectively. is to teach clients environmental intervention skills A client in skills training only may be seeing other so that clients can do environmental interventions care providers, such as a pharmacotherapist or other for themselves. New clients may be shocked at first type of health care provider. In these cases, the skills with this confidence that they will eventually suc- trainers interact with them as needed in the same ceed in learning these skills. But the shock is bal- manner that they interact with non-DBT therapists. anced with an emerging pleasure at being treated as That is, skills trainers consult to the client on how adults who can run their own lives. to work with the other care providers, and the client is present for any interactions of skills trainers with these care providers. Integrative Strategies Difficulties that individual clients experience with other therapists and clinical agencies can be There are six integrative strategies in DBT for re- dealt with in the skills training sessions if those sponding to the following specific issues and prob- difficulties can be made relevant to the skills being lems in treatment: (1) ancillary treatments, (2) taught. For example, in the Interpersonal Effective- crises, (3) suicidal behaviors, (4) therapeutic rela- ness module, an individual client may be helped to tionship issues, (5) telephone calls, and (6) therapy- communicate more effectively with other profes- interfering or -destroying behaviors. Telephone calls sionals treating him or her. In the Emotion Regula- and therapy- interfering or -destroying behaviors tion module, clients can be helped to modulate their have already been discussed in Chapters 3 and 4 of emotional reactions to these professionals. During this manual, respectively. In the remainder of this the Distress Tolerance module, they can be assisted chapter, I briefly review the strategies for ancillary in accepting and tolerating the behaviors of other treatments, crises, suicidal behaviors, and relation- professionals that they find problematic. Generally, ship problem solving as they apply to skills training. problems with treatment professionals brought up All these strategies are discussed in greater detail in in skills training sessions are dealt with in precisely Chapter 15 of the main DBT text. 5. Application of Fundamental DBT Strategies in Behavioral Skills Training 99 Ancillary Treatments of the crisis strategies used in individual therapy should be used; following resolution of the crisis, the There is nothing in standard DBT (skills train- client should be referred to individual DBT, other ing, DBT individual treatment, DBT team) that appropriate therapy, or intensive case management. proscribes ancillary health care, including mental Just as clients can be in a state of individual cri- health care, as long as these programs are clearly sis, a group can also be in a state of crisis. A group ancillary to DBT and not the primary treatment. in crisis is functioning in a state of emotional over- The basic idea here is that for clients in DBT, there load. Usually this will be the result of a common can only be one primary therapist responsible for trauma, such as a group member’s committing sui- the overall care of the client. In standard DBT, the cide, a hostile act directed at the entire group, or a individual DBT therapist is the primary treatment trainer’s leaving. In these instances, group leaders provider; overall treatment planning, crisis and sui- should employ all of the crisis strategies used in in- cide management, case management, and decisions dividual crisis intervention; they are simply applied about ancillary treatments are in the hands of this to the entire group instead of to one client. The steps therapist. As noted in Chapter 2 of this manual, a are summarized in Tables 5.1 and 5.2. similar stance is taken when an individual in DBT skills training has a non-DBT individual therapist or case manager instead of a DBT therapist. In both Suicidal Behavior Strategies cases, management of crises, suicidal behaviors, and If the risk of suicide is imminent and the client is ancillary treatment (e.g., emergency department or also in individual therapy, a skills trainer should call inpatient admission) is handled by the skills trainers the individual therapist immediately for instructions only until the primary therapist can be contacted. on how to proceed. As noted in Chapter 2 of this Once this therapist is contacted, client management manual, individual therapists (both DBT and non- will be turned over to him or her—or, if necessary, DBT) of skills training clients agree at the start to the skills trainer will carry out treatment directions be available by phone; to provide a backup provid- given by the primary therapist. er’s phone number to call if necessary during their If a client is in DBT skills training only, with no clients’ skills training sessions; and to provide an other mental health treatment provided, it is the re- up-to-date crisis plan. If neither a client’s individual sponsibility of the skills leaders to manage crises, therapist nor a backup therapist can be located, the suicidal behaviors, and any other client problems skills trainer must do crisis intervention until con- that arise in treatment. Depending on the skills of tact can be made with the individual therapist. If the skills trainers and the needs of the client, these the client does not have an individual therapist, the events may be managed completely by the skills skills trainer does crisis intervention and then refers trainers, or the client may be referred for ancil- the client for individual therapy if needed (in combi- lary individual treatment. If they are managed by nation with continued skills training). As a general the skills trainers, this will ordinarily require indi- rule, a skills trainer should be much more conserva- vidual sessions. Management of client suicidality or tive in the treatment of suicidal risk than is the in- of individual or family crises is extremely difficult dividual therapist. The crisis plan is a good place to in a group setting—particularly crises that are re- start. Steps for intervention when a client is threat- current, such as difficulties with a suicidal or drug- ening imminent suicide or self-injury, or is actually dependent spouse or child. engaging in self-injurious behavior during contact (or has just engaged in it), are discussed in detail in the main DBT text and are outlined in Table 5.2. Crisis Strategies When a skills training client in crisis is also in in- Relationship Problem Solving dividual therapy, skills trainers should (1) refer the client to the individual therapist and assist him or Relationship problem solving is the application of her in making contact if necessary; and (2) help the general problem-solving strategies to the therapeu- client apply distress tolerance skills until contact is tic relationship. In individual skills training, that made. The crisis strategies described in Chapter 15 relationship is between the trainer and the client. In of the main DBT text should be used in a modified group skills training, however, at least four relation- version. If the client has no individual therapist, all ships may require problem solving: (1) member ver- 100 I. AN INTRODUCTION TO DBT SKILLS TRAINING TABLE 5.1. Crisis Strategies Checklist Skills trainer attends to emotion rather than content. Skills trainer explores the problem now. Skills trainer focuses on immediate time frame. Skills trainer identifies key events setting off current emotions and sense of crisis. Skills trainer formulates and summarizes the problem. Skills trainer focuses on problem solving. Skills trainer gives advice and makes suggestions. Skills trainer frames possible solutions in terms the skills group is learning. Skills trainer predicts future consequences of action plans. Skills trainer confronts group maladaptive ideas or behavior directly. Skills trainer clarifies and reinforces group’s adaptive responses. Skills trainer identifies factors interfering with productive plans of action. Skills trainer focuses on affect tolerance. Skills trainer helps group commit itself to a plan of action. Skills trainer assesses group members’ suicide risk (if necessary). Skills trainer anticipates a recurrence of the crisis response. Note. Adapted from Table 15.1 in Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline per- sonality disorder. New York: Guilford Press. Copyright 1993 by The Guilford Press. Adapted by permission. sus group leaders, (2) group versus group leaders, (3) relationship with at least one of the group leaders member versus member, and (4) leader versus leader. if they are to continue in skills training. Without Not only are there more relationships to balance, such attachments, the trials, tribulations, and trau- but there are also many more issues coming into mas that frequently arise in skills training will over- play. The public nature of the relationships is partic- whelm the clients, and they will eventually drop out ularly important. Individuals who have difficulties of therapy. These individual relationships, which are regulating their emotions are exquisitely sensitive to distinct from a leader’s relationship to the group as any threat of rejection or criticism; when that rejec- a whole, are enhanced by individual attention given tion or criticism is public, they may experience such to group members before and after group meetings overwhelming and intense shame that it completely and during breaks. cuts off any chance of adequate problem solving. Relationship problems between group members Thus leaders have to be correspondingly sensitive in and group leaders should not be ignored. Depend- dealing with relationship problems in treating such ing on the seriousness of the problem, a problem- individuals. The relationship problem solving typi- solving meeting may take place before, after, or dur- cal of process therapy groups is simply not possible ing a break in a skills training session; on the phone; with individuals who are sensitive to rejection, emo- or in a scheduled individual meeting before or after tionally dysregulated, and without interpersonal a group meeting. Whenever possible, such an indi- skills. Therefore, some of this problem solving has vidual meeting should be scheduled near in time to to be conducted individually and outside the group the group session, so that it does not take on the sessions. Otherwise, problems may not be resolved character of an individual psychotherapy session. It and may escalate to such an extent that members is best to hold the meeting in a corner of the group find it impossible to continue in the group. therapy room or somewhere in the hall or waiting area. Also, the focus should be kept on the member’s problems with the group or with the leader. Member versus Group Leader As a first step, the leader should help the group It is essential for clients with high suicidality and/ member observe and describe exactly what the or severe emotion dysregulation to form an attached problem is and with whom he or she has the prob- 5. Application of Fundamental DBT Strategies in Behavioral Skills Training 101 lem. Sometimes the problem will be with one or ment, including those that show up in ancillary or the other leader. The public light of group sessions collateral treatment. At times, however, a client may seems to enhance members’ sensitivity to even slight also profit from some individual attention from the rejections or insensitive comments on the part of the group leaders. During such a meeting, strategies can leaders. Comments that might not lead to trouble be worked out to reduce the stress on the individu- in an individual interaction can lead to great prob- al member. For example, we have had some group lems in group therapy. Thus, if the problem is a lead- members who simply could not sit through an entire er’s behavior, problem solving should be centered group session without becoming hostile or having a around it. panic attack. In these cases, plans were developed At other times, however, the problem is not with so that when the clients saw that their behavior was a group leader’s behavior, but rather with the no- about to go out of control, they would get up and tion of attending and working in the group at all. leave the session for a few moments’ break. With individuals in ongoing individual therapy, Careful attention must be paid to issues of shap- these problems are usually dealt with by the indi- ing. Clients who have difficulties regulating their vidual therapist. The primary therapist assists the emotions are prone to indirect communication, client with all behaviors that interfere with treat- which at times requires mind reading by the skills TABLE 5.2. DBT Suicidal Behavior Strategies Checklist When threats of imminent suicide or self-injury are occurring, and skills trainer cannot turn management over to an individual therapist: Skills trainer assesses the risk of suicide and of self-injury. Skills trainer uses known factors related to imminent suicidal behavior to predict imminent risk. Skills trainer knows the likely lethality of various suicide/self-injury methods. Skills trainer consults with emergency services or medical consultant about medical risk of planned and/or available method(s). Skills trainer follows the crisis plan already prepared. Skills trainer removes, or gets client to remove, lethal items. Skills trainer emphatically instructs client not to commit suicide or engage in self-injurious behavior. Skills trainer maintains a position that suicide is not a good solution. Skills trainer generates hopeful statements and solutions for coping. Skills trainer keeps contact when suicide risk is imminent and high (until client’s care is stabilized). Skills trainer anticipates a recurrence (before care is stabilized). Skills trainer communicates client’s suicide risk to current or new individual therapist as soon as possible. When a self-injurious act is taking place during contact or has just taken place: Skills trainer assesses potential medical risk of behavior, consulting with local emergency services or other medical resources to determine risk when necessary. Skills trainer assesses client’s ability to obtain medical treatment on his or her own. If medical emergency exists, call emergency services. Skills trainer stays in contact with client until aid arrives. Skills trainer calls individual therapist (if there is one). If risk is low, skills trainer instructs client to obtain medical treatment, if necessary, and to call his or her individual therapist (if in therapy). Note. Adapted from Table 15.2 in Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Copyright 1993 by The Guilford Press. Adapted by permission. 102 I. AN INTRODUCTION TO DBT SKILLS TRAINING trainers. How much mind reading should a group rather than confront problems. In this event, the skills trainer engage in? How much outreach should withdrawal leads to positive outreach on the part of be made to a withdrawn group member? The goal is the skills trainer, a positive interaction, and some- to require group members to reach their capabilities times a positive resolution. The dialectical dilemma and if possible to go slightly beyond these, without here is the need to choose between avoiding rein- requiring so much that the members fall back in fail- forcement for withdrawal and allowing a member ure. At the beginning of skills training, leaders will to drop out. A leader simply has to face the fact that often need to telephone group members when they many clients who have trouble regulating their emo- miss sessions or after they storm out of sessions. tions cannot engage in problem solving alone. Thus, The key, however, is not to engage in this behavior in the interests of shaping, the leader should call, so reliably that clients begin to expect it, count on it, do problem solving, and then emphasize that the and become distressed if a leader does not reach out direct discussion of the problem does result in prob- or call. The best approach is for leaders to be direct lem resolution. Once this pattern is stabilized, then in their communications about what they will and the leader can gradually decrease the degree of out- won’t do. As discussed earlier in this chapter, the reach, while simultaneously verbally instructing the DBT policy is to reach out and call group members individual that he or she is expected to increase out- when such calling is not reinforcing maladaptive be- reach to the leaders and to the skills training group. haviors, and to refrain from reaching out when it While at the beginning the leader walks all the way will reinforce such behaviors. Obviously, such judg- over to the client’s side of this “teeter-totter,” he or ments are difficult. It is especially difficult at the be- she needs to grab the client and begin moving back ginning of skills training, when leaders have little toward the middle. Without this movement, the very idea of the group members’ respective capabilities; problems that outreach is intended to resolve may be in this case, it is important to make policies clear. In exacerbated. all cases, however, it is essential not to assume that With highly suicidal and/or dysregulated cli- a particular response on the part of the leaders is ents, leaders should expect to spend a considerable reinforcing. There is no substitute for observing the amount of time resolving crises related to skills consequences of various therapeutic actions. training. The key point is that interventions should Our general policies are as follows. If a member be limited to problems in the clients’ relationship to does not show up for a skills training session, that the group as a whole or to the group leaders. In other person is called immediately by one of the leaders crisis situations, leaders should instruct the clients and urged strongly to drop everything and come to call their individual therapists (or refer such a cli- to the group session immediately. This phone call ent to an individual therapist if the client does not is designed to cut off the person’s ability to avoid have one). If a leader suspects that phone calls may a group session. Clients with disordered emotion be reinforcing a client’s problem, outcomes of phone regulation often believe that if they don’t come to calls should be closely observed, and the possibility a group session, they won’t have to deal with group should be discussed openly with the client as yet an- issues; calling immediately interferes with the avoid- other problem to be solved. ance. The phone conversation should be kept strict- Because there are two leaders in group skills train- ly to a discussion of how the person can get to the ing, each leader should take great care to observe session, even if he or she arrives for only the last the consultation-to-the-client approach. That is, one half hour. We have at times even offered to send a leader should not become an intermediary between leader or a volunteer staff person out to pick up the a client and the other leader. A leader can, however, person when the reason for not coming is lack of work with the client on how to resolve a problem transportation. In short, the phone call in this situ- with the other leader. In my experience, it is rare ation serves to cut off reinforcement for avoidance for a group member to be having serious problems rather than to reinforce the avoidance behavior. (For with both group leaders at the same time. When this clients who know our clinic’s phone number and re- occurs, skills trainers must bring the topic up with fuse to pick up, we often use phones with other, un- their DBT therapist consultation team. known numbers to make our calls.) The most difficult problem to address—and the If a leader waits a few days to call, or if the phone easiest to ignore—is that of the group member who call addresses the person’s problems, then the call comes to every session and stays for the entire ses- may well reinforce the client’s tendency to withdraw sion, but either interacts in a hostile manner or 5. Application of Fundamental DBT Strategies in Behavioral Skills Training 103 withdraws. Once I had a group member who came ing and frustrating, the leaders’ refusal to give up and fell asleep during most group sessions. What I or give in and reciprocate with hostility or obvious wanted to do was reciprocally withdraw from the frustration communicates clearly to clients that no group member. When a leader withdraws from a matter what they do or how withdrawn they are, the group member, however, the group member can be group will progress and continue. expected to withdraw even further and eventually On the other hand, leaders can do only so much drop out. Addressing these issues directly in group with a group if the group members are withdrawn sessions can be threatening, can take up a lot of and not talking. In these situations, it is helpful to time, and is usually not a good idea as a first ap- be able to read the clients’ minds. It is sometimes proach. Since the group member is not directly ex- a good idea for the leaders to have a dialogue (out pressing a problem and is not asking for attention, it loud) with one another, trying to figure out the prob- is the leader’s responsibility to approach him or her lem. Although over time the group members should and set up an individual consultation before or after develop the ability to resolve group stalemates with a group session or during the break. the leaders via problem solving, at the beginning Failure to initiate an action is usually a sign that a progress is usually not visible. It is absolutely essen- leader is frustrated and, perhaps, is not motivated to tial in these situations that leaders not let their own keep the member in the group. At these times, hav- judgments and hostile interpretations have free rein. ing a second leader can be an enormous asset. The Compassion and empathy are essential. Sharing one leader can prod the other to address the issue. frustration with the DBT team can be very useful here. Individual therapists may have gathered help- ful information about reasons for the group’s dis- Group versus Group Leaders tress from their own individual clients. When the entire group is engaging in therapy- interfering behavior vis-à-vis the group leaders, the Member versus Member problem cannot, of course, be dealt with individu- ally; it is a group problem. When should this prob- Not infrequently, there is conflict between individu- lem be addressed directly, and when should it be ig- al members in a skills training group. In my experi- nored? An attempt to address the problem directly ence, encouraging group members to discuss their often backfires. Once group members have with- problems with one another openly in a group session drawn or begun to interact in a hostile manner, they almost always results in disaster. Again, clients who are often unable to stop the withdrawal in order to have trouble regulating their emotions often cannot process the problem. Any move on the leaders’ part tolerate criticism in a group setting; thus member- to address the problem is viewed as criticizing fur- to-member problems need to be dealt with privately ther or as creating more conflict, and the group sim- until the collective ability to solve problems pub- ply withdraws further. licly is increased. In private interactions with a dis- It is usually better either to ignore the group tressed group member (before or after a session or withdrawal or hostility, or to comment on it briefly during a break), a leader’s primary role is to soothe without pushing the issue and then focus on draw- the distressed member and to explain the offending ing out individual group members. At this point, it is member in a sympathetic manner. If criticisms or essential to be able to cajole, distract, and otherwise member-to-member conflicts arise during a session, respond to the problem in a relatively indirect man- a leader’s best strategy is to serve as the third point ner. If leaders reciprocate with hostility, coldness, or fulcrum. Rather than suggesting that the conflict- and withdrawal, the problem will increase. ing members talk with one another to resolve their This is perhaps one of the most difficult situa- differences or hurt feelings, the leader should pub- tions that group skills training leaders must face. licly defend the offending member while simultane- Unfortunately, it can often happen in the beginning ously empathizing with the offended member. If the months of a new skills training group, particularly conflict is over procedural issues, problem solving when members are forced to be in the group and can go forward in the group session. For example, really don’t want to be there. It is a bit like trying a conflict arose in one of our skills training groups to walk through quicksand—pulling with all one’s between one member’s need for the window cur- strength to get one foot up, and then putting it down tains to be closed and other group members’ need again in front of the other. Although it is exhaust- for the curtains to be open. Such conflicts should be 104 I. AN INTRODUCTION TO DBT SKILLS TRAINING mediated by a group leader, but can be discussed in always create problems. The public nature of the group sessions. A leader’s role in these cases is some- group setting simply exacerbates these problems. what like a parent’s or teacher’s role with a group Problems that individuals have with their families of quarreling children. The sensitivities of each in- or their children are likely to show up in the group. dividual member must be respected; a leader must Many members have problems in coping with au- resist the tendency at times to sacrifice one member thority figures, especially when the authority figures for the good of the whole. are telling them what to do. Others have problems with being authority figures and voicing their opin- ions. Therefore, at least some clients will have prob- Leader versus Leader lems doing homework practice. Some individuals Perhaps the most damaging conflict in conducting will have problems admitting to progress; others DBT group skills training is that which can arise may have difficulties admitting to lack of progress between the two group leaders. Smooth coordina- or to not knowing how to use a skill. tion can be especially difficult when the leaders have The inability of many individuals with high emo- different theoretical perspectives, when they take tion dysregulation to put personal problems on a different views of how groups should be conducted, shelf and attend to the skills training material is or when one or both leaders wish for a different role similar to their difficulties outside skills training in the skills training than the role assigned. These at work, at school, or with their family members. issues need to be resolved outside the skills training Their inability to remember to practice skills (or sessions, preferably before the first session. When to get themselves to practice even when they do re- conflicts arise in sessions, the usual procedure is for member), and then to punish or berate themselves in the co-leader to defer to the primary leader during a judgmental fashion, is indicative of their general the session and argue his or her case afterward. difficulties with self-management. Their tendency to A particular problem arises when the co-leader is withdraw emotionally and become silent when any better tuned in to group members and to the unfold- conflict occurs during group sessions is typical of ing process than the primary leader. This is a situa- their difficulties in dealing with conflict outside the tion where the DBT consultation team can be quite group. An often unstated, but particularly difficult, useful. No matter what the difference in experience problem of many group members is their inability between leaders may be, it is important for them to shut themselves off emotionally from other group not to fall into the trap of who is “right” and who members’ pain. Consequent exacerbation of their is “wrong.” Not only is this approach dialectically own painful emotions can result in either panic at- flawed, but it is rarely useful in resolving a conflict. tacks, hostile behavior, or complete emotional with- A related situation can occur when group mem- drawal. As can be seen from just this partial list, bers complain about an absent leader to the other skills training in a group setting can be counted on leader. How should the leader who is present react? to bring up many of the everyday problems that in- The most important thing is not to become split dividuals with emotion dysregulation have. off from the absent leader. The same strategy used Some group members who ordinarily have rea- when an absent member is being discussed should sonably good emotion regulation may have very be employed. That is, the present leader should por- little regulation when specific topics come up. This tray the absent leader in a sympathetic light, while is especially true in two types of situations. The first simultaneously validating the concerns of the mem- is when a client’s main problems are with a relative bers present. It is a tricky line to walk, but essential or close friend who also has a severe disorder, and nonetheless. whom the client cannot seem to help. The second is when the client’s family or close friends persistently do things that lead to misery for the client. Trouble Relationship Generalization arises in such cases when clients become determined Leaders must be vigilant in noticing when interper- to get the group leaders to help them figure out how sonal relationships within the group are similar to to change the other persons. These clients may view problems individuals are having outside group ses- their own use of skills as relatively hopeless, or may sions. A number of typical problems show up in have a blind spot about their own ineffective be- group skills training. The exquisite sensitivity to haviors. Often the only strategy that can work with criticism of individuals with emotion dysregula- these clients is to insist repeatedly that the focus of tion, and the rapid onset of extreme shame, almost skills training is on developing their own skills, not 5. Application of Fundamental DBT Strategies in Behavioral Skills Training 105 those of their relatives or friends. In these cases, it is alternative response patterns for members to try. essential that the skills leaders remain firm. At times The key in relationship generalization is to plan for an activity may need to be stopped to address the rather than to assume generalization. Planning, at a problem before continuing. In one of my groups, for minimum, requires discussion with the group mem- example, I was teaching problem solving. One client bers. The discussion should also include developing (whose problem with her son was the example to homework in which clients can practice applying be solved) repeatedly insisted that the only possible new skills to everyday situations. Since this is the es- solutions were new behaviors from her son. All at- sential idea undergirding skills training and home- tempts by me to focus on solutions that the mother work practice anyway, relationship generalization is could implement were met with tears and screams especially compatible with DBT skills training. that she was being invalidated. I finally realized I could not use that problem to demonstrate problem The Appendices to Part I, which follow this chap- solving, said as much, and made up a new example ter, provide a wide variety of options for structur- to work with. I then discussed the issue with the cli- ing DBT skills training programs. Part II of this ent at the end of the group session. manual (Chapters 6–10) presents instructions for The basic idea of relationship generalization strat- how to orient clients to skills training and to teach egies is to help members see when their everyday the four DBT skills training modules. The hand- problems are showing up within the skills training outs and worksheets for skills training clients can group. However, this can be quite tricky, because be found on the special website for this manual it must be done without invalidating clients’ real (www.guilford.com/lin-manual) and may be problems with the group or with specific members. downloaded and printed. It is important that leaders not be overinclined to at- tribute all within-therapy problems to outside prob- References lems, rather than to inadequacies in the group for- mat or to the leaders’ application of the treatment. 1. Linehan, M. M. (1997). Validation and psychothera- Clients’ difficulties in accepting negative feed- py. In A. C. Bohart & L. S. Greenberg (Eds.), Em- back or implied criticism suggest that leaders must pathy reconsidered: New directions in psychotherapy be extremely sensitive in applying the relationship (pp. 353–392). Washington, DC: American Psycho- generalization strategies. In my own experience, the logical Association. best way to do this is to take an individual problem, 2. Cayne, B. S., & Bolander, D. O. (Eds.). (1991). New make it into a universal problem, and then discuss Webster’s dictionary and thesaurus of the English lan- it in that context. Astute group members may figure guage. New York: Lexicon. out that they are the ones being talked to, but still it 3. Whitaker, C. A. (1975). Psychotherapy of the absurd: With a special emphasis on the psychotherapy of ag- is not a public humiliation. gression. Family Process, 14, 1–16. The first step in relationship generalization is to 4. Bower, G. H., Black, J. B., & Turner, T. J. (1979). relate the within- session relationship problem to Scripts in memory for text. Cognitive Psychology, general problems that need work both in and out of 11(2), 177–220. the skills training group. Just making this connec- 5. Friedman, A. (1979). Framing pictures: The role of tion (an insight strategy; see Chapter 9 of the main knowledge in automatized encoding and memory for DBT text) can sometimes be therapeutic. The next gist. Journal of Experimental Psychology: General, step is to use problem-solving strategies to develop 108(3), 316–355.