DBT Skills Training Sessions PDF

3. Structuring Skills Training Sessions 53 then they cannot miss four scheduled individual ses- 1. People are doing the best they can. The idea sions in a row. If they are in another form of individ- here is that all people at any given point in time are ual therapy, then the attenda...

3. Structuring Skills Training Sessions 53 then they cannot miss four scheduled individual ses- 1. People are doing the best they can. The idea sions in a row. If they are in another form of individ- here is that all people at any given point in time are ual therapy, then the attendance guidelines of that doing the best they can, given the causes of behavior treatment must be followed. The exception to this that have occurred up to this moment. rule is when clients are on a waiting list for therapy. 2. People want to improve. The common char- Data collected by a Canadian research team found acteristic of all people is that they want to improve that skills training alone was effective in reducing their lives. As noted by the Dalai Lama at a meeting suicide attempts in suicidal individuals on a treat- I was part of, a common characteristic of all people ment waiting list.3 is that they want to be happy. This early emphasis on the likely need of highly 3. *People need to do better, try harder, and be dysregulated and/or suicidal participants for extra more motivated to change. The fact that someone is help in mastering the skills is very important later doing the best he or she can and wants to do even when the clients run into difficulty. It is all too easy better does not mean that this is enough to solve the for the skills trainers to overestimate the ease of problem. (The asterisk here means that this is not learning skills; such overestimation sets the clients always true. In particular, when progress is steady up for later disillusionment and hopelessness. and is occurring at a realistic rate, with no let-up or DBT skills training does not require that the in- episodic drop in effort, doing better, trying harder, dividual therapist be a DBT therapist. Nonetheless, and being more motivated are not needed.) the requirement for individual therapy can still be 4. *People may not have caused all of their own quite formidable at times. In our experience, it is problems, but they have to solve them anyway. Peo- not uncommon for individual therapists in the com- ple have to change their own behavioral responses munity to get pushed past their limits by clients and alter their environment for their lives to change. with dysregulated emotions, and then to terminate (The asterisk here indicates that with children or therapy precipitously with these clients. When this disabled persons, others might be needed to solve happens, it can be extraordinarily difficult to find some problems. For example, young children can- an individual therapist willing to work with such not get themselves to treatment if parents or others clients, especially with those who are mourning the refuse to take them.) loss of previous therapists. This is especially prob- 5. New behavior has to be learned in all relevant lematic when the clients cannot afford to pay the contexts. New behavioral skills have to be practiced high fees often charged by professionals who are in the situations where the skills are needed, not just experienced enough to be helpful. Unfortunately, in the situation where the skills are first learned. many public health clinics are so understaffed that 6. All behaviors (actions, thoughts, emotions) they cannot provide individual psychotherapy, or are caused. There is always a cause or set of causes clients may have already burned out their local clin- for actions, thoughts, and emotions, even if people ics. In these cases, the skills training leaders often do not know what the causes are. must function as short-term backup crisis therapists 7. Figuring out and changing the causes of be- and assist the clients in finding appropriate individ- havior is a more effective way to change than judg- ual therapists. ing and blaming. Judging and blaming are easier, but anyone who wants to create change in the world has to change the chains of events that cause un- Presenting DBT Assumptions wanted behaviors and events. The assumptions underlying treatment are outlined in General Handout 4 and described below. Along with the skills training guidelines, they are present- Format and Organization ed and discussed with skills participants during ori- of Ongoing Skills Training Sessions entation (which is repeated before the start of each Mindfulness skills module) and in person with cli- The structuring of session time is the major factor ents who join a skills group after the first session of differentiating formal DBT skills training from DBT a module. An “assumption” is a belief that cannot individual psychotherapy. In individual DBT psy- be proved, but group members agree to abide by it chotherapy, the agenda is set by a client’s behavior anyway. DBT across the board is based on the fol- since the last session and within the current session; lowing assumptions. the agenda is open until the client shows up for the 54 I. AN INTRODUCTION TO DBT SKILLS TRAINING session. In skills training, the therapy agenda is set Table 3.4. Each of the four sections is discussed in by the behavioral skill to be taught; the agenda is set more detail below. before a client shows up for the session. Some inpatient settings have split this format in Skills training sessions require at least four sec- two, holding two weekly sessions—one devoted to tions: (1) a beginning ritual, (2) review of homework homework review and one devoted to new skills. practice since the last session, (3) presentation of This is a reasonable model on inpatient and day new material, and (4) a closing “wind-down.” In my treatment units, where staff members have some clinic, skills training sessions for individuals with ability to persuade clients to attend both weekly ses- severe disorders (including BPD) last for 2½ hours, sions. In an outpatient setting, however, there is a generally with a 15-minute break in the middle. The danger that clients will not attend homework review format is reasonably consistent for the whole year. sessions when they have not practiced any of their The sessions begin with a mindfulness exercise, fol- skills during the preceding week. Skills trainers will lowed by group members’ sharing their attempts (or want to prevent that from occurring. lack of attempts) to practice behavioral skills dur- Other settings have shortened the session time, ing the preceding week, followed by a break. The usually from 2½ to 1½ hours. In my clinic’s experi- second hour is devoted to presenting and discuss- ence with adults with severe behavioral and emo- ing new skills. The last 15 minutes are allotted to tional dyscontrol, 1½ hours is not enough time for a a session wind-down, which involves going around group session. Even with 2½ hours, 50–60 minutes the room and having each person share one observa- for homework review with eight group members tion about the session (a practice of the mindfulness gives each member about 6–8 minutes of group at- skills of observing and describing). tention—not very much. Nor is 50–60 minutes for This format varies slightly for the final session of new material much time, either. Although group each module. Instead of presenting new material, leaders can present a lot of material in that time, that session’s second half is devoted to a review of they also need time to do in-­session practice of new all the skills from that module; a review of skills skills, to discuss questions about the week’s new from the previous modules; and a discussion of pros content, to check skill comprehension with each and cons of using the skills and skill generalization member, and to go over new homework sheets to be across situations and contexts in participants’ lives. sure that clients understand how to do the practice The session concludes with a wind-down, which can and how to record it. Individual skills training can consist of observations about the module as a whole be accomplished in weekly 45- to 50-minute ses- and how the weeks and sessions on the module went. sions. If any individuals are leaving the skills training group, there is time set aside to say goodbye and Session Room Setup and Materials discuss termination issues. Generally, we ask those leaving for ideas on snacks for the last meeting, and It is important to set up the room for skills train- also let them choose the mindfulness practice at the ing sessions differently from what is usually done beginning of the group. We give (standing with the for traditional group or individual therapy. To the participant by our side) each graduating person a degree possible, the aim should be to elicit a sense graduation certificate signed by the two co-­leaders of being in a classroom. We conduct our group ses- and a graduation card with personal notes from sions in a conference room around a table, with a each leader. Unless there is a good reason for not whiteboard for the skills trainers to write on. For doing so, we end the session with each person given an opportunity to say a personal good bye. In sum, you want to give departing participants a positive sendoff. TABLE 3.4. Standard Skills Training Session Format In our friends-and-­family program and in skills training for participants with less severe disorders, Beginning ritual (mindfulness exercise) groups last from 90 minutes to 2 hours. Adolescent Review of homework practice groups also last from 90 minutes to 2 hours. Indi- Break vidual skills training sessions ordinarily last 45–60 Presentation of new material/skills minutes. In each case, however, the general four- Closing wind-down part structure of sessions is the same as outlined in  3. Structuring Skills Training Sessions 55 individual skills training, we bring in a small desk his or her experience with the group. This sharing for the client to sit at; if this is not possible, we teach is very important, as it does not take much time individual skills in a room different from the indi- and gives the leader or co-­leader a chance to pro- vidual therapy room. Skills training handouts and vide corrective feedback if needed. If members have worksheets for all modules to be taught are given missed one or more previous sessions, they are given out in three-ring binders with pockets in front and a chance to tell the group where they have been. If back. Handouts are printed on one color of paper, missing sessions is a problem for a person, attention and worksheets on another color. Generally, we try (no more than 5 minutes or so) can be paid to ana- not to use white paper, as it makes it more difficult lyzing what interferes with coming and how to over- for those with dyslexia to read. We also use labeled come it. If there are group issues (e.g., announce- dividers between sections and between handouts ments; not calling when missing; or coming late), and worksheets within sections. In the front binder they are dealt with at the beginning of the session. pockets, we put forms to track weekly practice as- This brief attention to therapy-­interfering behaviors signments; in the back pockets, we put a supply of is very important and should not be dropped. DBT diary cards. The diary card lists the most im- A therapist who is conducting individual skills portant DBT skills taught. Next to each skill on the training should follow the session-­beginning guide- card is a space for recording whether or not the cli- lines in Chapter 14 of the main DBT text—­greeting ent actually practiced the skill on each day during the client with warmth; attending, if only briefly, to the week. (See Chapter 4 and Figure 4.1 for more the client’s current emotional state; and repairing re- details about the diary card, as well as Chapter 6 of lationship difficulties at the beginning of a session if the main DBT text.) Pencils/pens for taking notes needed. Only a limited amount of time should then are available on the table. Clients are instructed to be spent on beginning strategies. If possible, the bring in their binders each week. Loaner binders are therapist should help the client use his or her distress available if they forget their own. tolerance crisis survival strategies (see Chapter 10 of Other materials to bring to the session include a this manual) to manage current emotions if extreme small bell that can be rung to start and end mindful- and distract from the need for further repair, do ness practices, and a selection of distress tolerance skills training, and get back to repair at the end of tools (e.g., cold gel pack, rubber ball with spikes, the session or at the next individual psychotherapy balance board) for use by people who may be in meeting. danger of dissociating during the sessions. It can also be useful to record sessions on video, if the nec- Review of Homework: essary equipment is available. (For more on this, see Sharing of Homework Practice Efforts the discussion in Chapter 4 on managing the home- work review.) The next phase of treatment is the sharing of At our group sessions, we serve decaffeinated cof- between-­session efforts to practice the specific be- fee and tea (and usually snacks as well). Before the havioral skills (mindfulness, interpersonal effective- beginning ritual, members get coffee or tea and a ness, emotion regulation, distress tolerance) being snack and get settled. In our groups, if people want taught. In our group sessions, the primary group to bring their own snacks, then they have to bring leader goes around the circle and asks each member enough to share with everyone. to share with the group what he or she has prac- ticed during the preceding week. In my experience, waiting for members to volunteer takes up too much Session-­Beginning Ritual time. However, I may let members decide who to We begin with the session leader or co-­leader lead- start with in going around the circle. Vocabulary ing a mindfulness practice. An effort is made to vary can be very important here. Behaviorists are used to the practices so that over the weeks we practice each calling practice “homework,” and therefore to ask- of the mindfulness skills. Mindfulness practices are ing clients about their “homework practice.” Some listed on Mindfulness Handouts 4a–4c and 5a–5c. of our clients like this terminology and prefer to We start each practice by ringing the mindfulness think of skills training as a class they are taking, bell three times, and end it by ringing the bell once. much like a college course. Others feel demeaned by Then we go around the room and ask each partici- the words, as if they are being treated like children pant (including the leader and co-­leader) to share in school and once again having to report to adults. 56 I. AN INTRODUCTION TO DBT SKILLS TRAINING A discussion of the semantics at the very beginning Chapters 7–10 is presented in this part of the ses- of treatment can be successful in defusing this issue. sion. The weekly sharing of homework practice ef- The first 30 minutes of each new skills training forts is an essential part of skills training. The sure module (remember that there are four) is spent in knowledge that not only will each client be asked discussing the rationale for that particular module. about his or her efforts to practice skills, but that (In an ongoing group, the time devoted to home- not practicing will be analyzed in depth, serves as work review is cut short during the first session a powerful motivation for at least attempting to of each iteration of the Mindfulness module.) The practice skills during the week. The norm of weekly leaders’ task here is to convince the clients that the in vivo practice is set and maintained during the skills to be covered in the upcoming module are sharing. Every client should be asked to share his relevant to their lives; that if they improve these or her experiences, even those who communicate particular skills their lives will improve; and, most extreme reluctance or aversion to the task. This part importantly, that they can actually learn the skills. of the session is so important that its completion The leaders often have to be creative in demonstrat- takes precedence over any other group task. To fin- ing how particular sets of skills apply to particular ish the sharing in the 50–60 minutes allotted takes problems. The specific rationales for each module very good time management skills on the part of are described in Chapters 7–10. the primary leader, as noted above. However, the usual absence of one or more clients, together with Closing Wind-Down the equally usual tendency of one or two each week to refuse to interact more than briefly, adds consid- Allotting time at the end of a group skills train- erably to the time per person available for sharing. ing session for winding down is very important for Managing homework practice is discussed further clients with emotion dysregulation. These sessions in Chapter 4 of this manual. are almost always emotionally charged and painful for some. Individuals who have difficulties regulat- ing their emotions are acutely aware of the negative Break effects of their own skill deficits. Without emotion Most clients get restless after about an hour of a regulation skills of their own, clients can be in great group session. We usually take a 10- or 15-minute emotional difficulty after a session, especially if break at about the halfway mark. Members can get nothing is done to help them regulate their affect a refill of coffee or tea, and a snack if snacks are and end or “close up” the session, so to speak. provided. Most clients go outside for fresh air. This A wind-down period also provides a time for cli- part of the session is important, because it provides ents who have dissociated during the session, usu- an unstructured period of time for group clients ally because of painful memories, to come back into to interact. Generally the group leaders stay near the session before parting. I was alerted to this need but somewhat apart from group clients during the during my first DBT skills training group. After break. Group cohesion, independent of the leaders, several months, it came up in a group discussion is thus fostered. If a member needs individual at- that almost every member of the group was going tention from a leader, however, it is given at this out drinking after the meetings as a means of af- point. One of our main problems has been that fect control. Skills trainers will often find that topics clients having a hard time at a session often leave that seem very innocuous are actually very stress-­ during the break. We have found it advisable to be provoking for individuals with disordered emotion particularly alert to anyone who may be leaving, so regulation. For example, a group member once be- that intervention can be attempted before he or she came extremely emotional and disorganized as I was walks out. introducing the Interpersonal Effectiveness module and the fact that one task of the module would be to learn to say no effectively. She was currently en- Presentation of New Material meshed in a group of drug dealers who frequently The hour after the break is devoted to the presen- raped her. She didn’t say no because the group was tation and discussion of new skills or, if necessary, her meal ticket. the review of ones already covered. The material in Wind-downs should last from 5 to (at most) 15  3. Structuring Skills Training Sessions 57 minutes. I have used several wind-down methods. group changes that they have noticed. Such insights The most popular with our group members is the highlight and foster the growth of dialectical think- “observe and describe” wind-down. Each member ing. In a group context, comments about group describes one thing he or she observed during the members’ behavior not only communicate to the session. The observation can be of liking or disliking individuals in question, but give information to all an event that occurred during group (e.g., “I liked members about how they can evaluate and interpret the mindfulness exercise today”), something some- their own behavior. one else did (e.g., “Suzy came on time and stayed the Although the process-­observing wind-down may whole time”), or a description of a self-­observation be very useful, it is also the type of wind-down with (e.g., “I felt really sad when talking about my fa- the most potential for creating problems. These ther”). The idea in this exercise is for the leaders to problems almost always happen when the obser- coach the clients in how to describe just the facts vation period gets out of the leaders’ control and they observed, without adding assumptions and in- ends in overly critical observations, in escalating terpretations to the facts. For example, instead of responses to critical feedback, and occasionally in saying, “I noticed I did better this week than last,” a members’ storming out and refusing ever to come client might be coached to say, “The thought arose back. This can be a particular problem when more in my mind that I did better this week than last.” experienced or advanced clients (e.g., those who Instead of “I noticed that Bill was really angry this have gone through several skills training modules) week,” the client might say, “I noticed thinking that are mixed with those who are just beginning skills Bill was really angry this week.” A therapist who is training. The more advanced clients may be ready conducting skills training individually should follow for much more process than new clients can toler- the session-­closing strategies in Chapter 14 of the ate. The process-­observing wind-down is a natural main DBT text. place for advanced clients to begin to try out more With more advanced groups, a process-­observing confrontational comments. I discuss the problems of wind-down can be used. In this method, we spend too much process work in first-year skills training between 5 and 15 minutes sharing our observations groups more thoroughly in Chapter 5 of this man- of how things went in the session. Members may ual. In both these types of “observe and describe” offer observations about themselves, one another, wind-downs, it is important that the group lead- the leaders, or the group as a whole. Although the ers go last. When necessary, this gives the leaders a leaders may have to model such observations at the chance to make an observation that pulls the group beginning, members usually pick up on the method together and repairs any damage that might have rapidly. As time passes and the group progresses, been done by others’ observations. we find that members usually become quite astute Other wind-downs might consist of clients’ bring- observers and describers of one another’s behavior, ing in music that is soothing and uplifting. (No progress, mood changes, and apparent difficulties. music extolling drug use or suicide!) Each member At times, the leaders may facilitate more in-depth can say what he or she is going to be doing for the observations and comments by asking general ques- next week. Any current news or sports event can be tions about observations (e.g., “What do you make discussed if it is relevant to most if not all the group of that?”). Or the leaders may encourage a mem- members. Any topic (favorite movies, animals, ber to check out an observation, especially when an movie stars, books, foods, etc.) can be discussed. observation involves an inference about another’s The list of topics is up to group leaders’ imagination feelings, mood state, or opinion. Another impor- and common sense. tant leader task is to draw out members who do not spontaneously offer an observation. During wind- down, each member should be encouraged to offer Observing Limits at least one observation, even if that observation is simply that it is difficult to offer an observation. DBT does not generally believe in setting limits, but An observing wind-down is also an opportunity to instead favors observing naturally occurring limits. utilize insight (interpretation) strategies in a group In skills training, however, a number of limits are setting. It is particularly useful for the group leaders set by the therapy itself. These limits are arbitrary, to comment on patterns of group interactions and in that I could conceivably have developed different