Skills Training Treatment Targets and Procedures PDF

Chapter 4 Skills Training Treatment Targets and Procedures As discussed in Chapter 3, DBT organizes treatment agement, exposure-based, and cognitive modifica- by levels of disorder and stages of treatment. Within tion procedures. Ski...

Chapter 4 Skills Training Treatment Targets and Procedures As discussed in Chapter 3, DBT organizes treatment agement, exposure-based, and cognitive modifica- by levels of disorder and stages of treatment. Within tion procedures. Skills training procedures, as their each stage of treatment, DBT focuses on a hierar- name suggests, will be the “meat” of interventions chy of behavioral targets highlighting behaviors to in behavioral skills training. However—and this is increase and behaviors to decrease. The hierarchy important—it is impossible to do a competent job helps ensure that the most important behaviors are in skills training without an understanding of how attended to first. When clients enter skills training to make contingencies work with a client (contin- in standard DBT, and when DBT skills training is gency procedures); how to manage exposure to combined with other modes of treatment (such as threatening material and situations (exposure-based milieu treatment), treatment targets are divided procedures); and how to deal with maladaptive among the modes of treatment. For example, when expectancies, assumptions, and beliefs (cognitive a Stage 1 client presents with life-­threatening be- modification procedures). In most senses, these pro- haviors, severe therapy-­interfering behaviors, and/ cedures cannot be pulled apart from the implemen- or severe quality-of-life-­interfering behaviors, then tation of skills training procedures; I do so here in decreasing these behavioral patterns would be the this chapter only for the sake of exposition. The primary treatment targets of the individual thera- next chapter describes the other three sets of change pist or case manager. PTSD and other serious men- procedures, along with other DBT strategies. tal disorders would ordinarily be treated also by an individual provider. In all stages of treatment (see Table 3.2), the task of the skills trainer is to increase Skills Training Behavioral Targets skillful behavioral patterns. This chapter begins with a discussion of skills training targets and con- Skills training behavioral targets, in order of impor- tinues with a discussion of skills training strategies tance, are (1) stopping behaviors that are very likely used to achieve those targets. A detailed discussion to destroy therapy; (2) skill acquisition, strengthen- of how to manage the homework review portion of ing, and generalization; and (3) reducing therapy-­ the session ends the chapter. interfering behaviors. The agenda for skill acquisi- “Strategies” are coordinated activities, tactics, tion, strengthening, and generalization is presented and procedures that a skills trainer employs to in Chapters 7–10 of this manual. Although this agen- achieve treatment goals—in this case, the acquisi- da is the impetus for skills training in the first place, tion and use of behavioral skills. “Strategies” also it must be set aside when behaviors emerge that are include coordinated responses that the provider likely to destroy the treatment, either for a specific should give to a particular problem presented by person or (in a group context) for the group as a a client. These, along with other DBT procedures, whole. In contrast to DBT individual psychothera- are how skills trainers address skills training tar- py, however, behaviors that slow down progress in gets. In the context of DBT as a whole, skills train- therapy (rather than threaten to destroy it altogeth- ing procedures constitute one of four sets of change er) are last rather than second in the hierarchy. As procedures; the other three are contingency man- noted in Chapter 3, the primary target behaviors for 61 62 I. AN INTRODUCTION TO DBT SKILLS TRAINING individual psychotherapy in DBT are (1) decreasing target behaviors are self-­ injurious acts (e.g., cut- suicidal and other life-­threatening behaviors; (2) de- ting or scratching wrists, picking off scabs so that creasing therapy-­interfering behaviors; (3) decreas- bleeding starts, taking excessive medications) and ing quality-of-life-­ interfering behaviors; and (4) suicide crisis behaviors during group sessions, in- increasing behavioral skills. A comparison of this cluding breaks (e.g., threatening suicide in a credible hierarchy with that for skills training indicates the manner and then storming out of the session). Also role of skills training in the total scheme of things. A included are behaviors that make it impossible for therapist who is conducting both the individual psy- anyone to concentrate, focus, or hear what is going chotherapy and skills training for a particular client on (e.g., yelling, hysterical crying, loud moaning, or must be very clear about which targets take priority constant out-of-turn talking). At times, an interper- in which treatment modes. Maintaining the distinc- sonal problem among group members or between tion between skills training and individual therapy members and leaders, or a structural problem in the is one of the keys to successful DBT. way skills training is delivered, may be so serious Successfully addressing skills training behavioral that skills training will fall apart if it is not attended targets requires an integration of almost all the DBT to. For example, one member may not be able to treatment strategies. This can be extremely difficult come back to skills training because of an interper- in Stage 1 of DBT (see Chapter 3 of this manual and sonal clash, hurt feelings, excessive hopelessness, or Chapter 6 of the main DBT text for a discussion of the like. In these cases, repairing the problem should stages), because often both clients and trainers do be the priority. A therapist may attend to an indi- not want to attend to skills training. Work on the vidual problem by phone between sessions or before therapeutic process, having “heart-to-heart” talks, or after sessions, if not in the session itself. Finally, resolving real-life crisis, and so forth can all be more a united rebellion of the clients against the trainers reinforcing (for both trainers and clients) than the is also considered a top-­priority target, as is a rebel- sometimes mundane task of working on general be- lion of the trainers against the clients. havioral skills. However, a trainer who ignores the The skills trainer’s goal is to stop therapy-­ target hierarchy is not doing DBT skills training. destructive behaviors and repair “rips” in the thera- That is, in DBT what is discussed is as important peutic “fabric” as quickly and efficiently as possible. as how it is discussed. Difficulties in getting a cli- For clients in standard DBT, further work on the de- ent to go along with the targets should be treated structive behaviors is left for the individual therapist as problems to be solved. A trainer who is having to handle. With or without an individual therapist, trouble following the target hierarchy (a not unlike- an individual meeting before or after a skills train- ly problem) should bring up the topic in the next ing session may be called for. Although teaching cli- therapist consultation team meeting. The following ents interpersonal effectiveness, emotion regulation, discussion addresses each target in the skills train- distress tolerance, or mindfulness skills may be use- ing hierarchy. ful in reducing the destructive behavior, a number of other treatment strategies may be necessary to bring these behaviors under control quickly (e.g., use of Priority 1: Stopping Behaviors Likely both positive and aversive contingencies). to Destroy Skills Training When a client is engaging in behaviors that are The highest-­ priority target is stopping client be- clearly destructive to skills training, the skills train- haviors that, when and if they occur, pose a seri- ers must respond promptly and vigorously. A modi- ous threat to the continuation of therapy. The em- fied version of the therapy-­interfering behavior pro- phasis here is a simple matter of logic: If therapy tocol described in Chapter 15 of the main DBT text is destroyed, other targets cannot be achieved. The can be applied here; the strategies, modified for use object is to maintain the skills training sessions. The in a skills training setting, are listed in Table 4.1. behavior has to be very serious to be considered this high in priority. Included in this target are vio- Managing Suicidal Behaviors lent behaviors, such as throwing objects, pounding loudly or destructively on things, and hitting or ver- When suicide crisis behaviors occur (which by defi- bally attacking other clients during group therapy nition suggest a high likelihood of impending sui- sessions. (Verbal attacks on the skills trainers are cide), skills trainers do the absolute minimum crisis not considered therapy-­destroying behavior.) Other intervention necessary and then, as quickly as pos-  4. Skills Training Treatment Targets and Procedures 63 TABLE 4.1. Therapy-­Destroying Behavior ing should not be interrupted to attend to a suicidal Strategies Checklist crisis.    Skills trainer behaviorally defines what client is Attention to suicidal ideation and communica- doing to destroy therapy. tions during skills training is limited to helping the client figure out how to apply the DBT skills    Skills trainer conducts a brief analysis of destructive behavior. currently being taught to the suicidal feelings and thoughts. During mindfulness training, the focus    Skills trainer makes contingencies very clear for continued destructive behaviors. may be on observing and describing the urge to en- gage in self-­injury or thoughts of suicide as these    Skills trainer adopts a problem-­solving plan with come and go. During distress tolerance training, client. the emphasis may be on tolerating the pain or using    When client refuses to modify behavior: crisis intervention skills to cope with the situation.    Skills trainer discusses goals of skills training During emotion regulation training, the focus may with client. be on observing, describing, and trying to change    Skills trainer avoids unnecessary power the emotions related to suicidal urges. In an inter- struggles. personal effectiveness framework, the emphasis    If client has an individual primary provider, skills may be on saying no or asking for help skillfully. trainer refers client to primary provider for an The same strategy is used when the client discusses in-depth behavioral analysis of the destructive life crises, problems interfering with quality of life, behavior. or previous traumatic events in his or her life. Ev-    If client does not have an individual primary erything is grist for the skill application mill, so to provider, skills trainer considers either requiring speak. Strategies for assessment and management of client to obtain a primary provider, or—in extreme cases—putting client on vacation from skills suicide risk when individual therapists are not avail- training until there is evidence that behavior has able are outlined in Chapter 5 of this manual (see come under control. especially Table 5.2). Note. Adapted from Table 15.5 in Linehan, M. M. (1993). Cognitive-­behavioral treatment of borderline personality disorder. Managing Skills Trainers’ Desire to Get Rid New York: Guilford Press. Copyright 1993 by The Guilford Press. Adapted by permission. of Difficult Clients It is not infrequent that skills trainers decide that the solution to dealing with difficult clients is to sible, turn the problem over to the individual thera- kick them out of skills training. In a very friendly pist or to area crisis services. Except to determine group, for example, you may have a new member whether immediate medical care is needed, reports who is loudly grumpy or sulks most weeks, taking of previous self-­injurious acts are given almost no up a lot of your time. A person may be hostile to attention during a skills training session. “Remem- you and other group members, or may routinely say ber to tell your therapist” is the modal response insensitive and mean things to others. In a group for those in individual psychotherapy. (As noted in where most do homework, one person may refuse Chapter 3, suicidal individuals and those with se- to do homework and complain about the need to vere disorders must have an individual therapist to do homework, requiring you to analyze the missing participate in skills training.) The one exception, as homework on a weekly basis. Others may routinely noted above, is when these behaviors become de- insist on talking about complicated personal prob- structive to the continuation of therapy for other lems, and may accuse you of being insensitive or un- group members. They are then targeted directly in caring when you try to reframe the problem in terms the skills training group sessions. The general prin- of skills that could be used. A client may frequently ciple is that skills trainers treat a client in a suicidal sob, yell, or bang the table so loudly in group ses- crisis like a student who gets deathly ill in school. sions that it is difficult to proceed. Clients may put The nearest relative (in this case, the individual their feet on the table and refuse to put them down, therapist or case manager) is called. A skills trainer loudly empty purses or backpacks on the table every who is also the individual client’s therapist should week to clean them out, bring in alcohol disguised turn to the problem after the skills training session. as cola, and argue vehemently with every point you Unless it is impossible to do otherwise, skills train- try to make. In over 30 years of conducting DBT 64 I. AN INTRODUCTION TO DBT SKILLS TRAINING skills groups, I have never kicked out a group mem- tacking and to lower tension between you and ber. I have nevertheless many times felt sure that a the individual and in the room. group would go better if I could just get rid of one 5. Use the DEAR MAN, GIVE FAST skills (see or two participants. When a troublesome person fi- Interpersonal Effectiveness Handouts 5, 6, nally does leave a group, however, someone else in and 7) to ask a person to stop behaviors that the group usually then becomes a problem. In other distract you or others. Use the “broken re- words, I have never seen a group improve by get- cord” and negotiate (Interpersonal Effective- ting rid of a member. In the majority of cases, I have ness Handout 5) if necessary. found that my ability to manage a difficult group 6. Put problem behaviors on an extinction sched- participant with equanimity and a lightness of tone ule (see Interpersonal Effectiveness Handout has allowed other group members not only to cope 21), and plunge in where angels fear to tread with disturbance, but also to find ways of appreciat- by acting as if clients are cooperating even ing the contributions that the difficult member often when they are not. does manage to make. Priority 2: Skill Acquisition, Managing Skills Trainers’ Desire to Attack Strengthening, and Generalization Difficult Clients With very few exceptions, most of the skills train- Skills trainers often have an intense desire for group ing time is devoted to acquisition, strengthening, skills training to go well for everyone. When one and generalization of the DBT behavioral skills: person threatens this desire, it is natural for group core mindfulness, distress tolerance, emotional leaders’ anxiety to increase, along with their at- regulation, and interpersonal effectiveness. Active tempts to control the offending group member. practice and use of behavioral skills are extremely When efforts to control disruptive behaviors fail, it difficult for individuals with highly disordered emo- is easy to become overprotective of the other par- tion regulation, since these require them to regu- ticipants. When that happens, anger and judgmen- late their own behavior in the service of practicing talness can increase, and when this happens, you skills. Thus, if passive and/or dysregulated behavior suddenly are at risk of therapy-­interfering behavior is followed by a group leader’s shifting attention to yourself. There have been many groups where I have another member (in a group context) or by a discus- held onto the table legs to keep myself from storm- sion of how the client is feeling or why he or she ing out of the room, or cursing group members for doesn’t want to participate, this risks reinforcing the being so ungrateful for my hard work. In these dif- very behavior (passivity or dysregulation) that skills ficult situations, it can be very hard to teach without training is intended to reduce. At times, trainers can being judgmental, and “emotion mind” is easy to simply drag clients through difficult moments in fall into. What to do at these points? Attack or with- skills training; such an approach, however, requires draw? If ever there is a time for skills trainers to use the trainers to be very sure of their behavioral as- their own DBT skills, this is the time. All of your sessments. The key point is that such an approach skills can be helpful. Here are just a few examples: should be strategic rather than simply insensitive. For example, there are times when it is more skillful 1. Observe what a difficult client is actually to leave a skills participant alone for a while. This doing, and describe it nonjudgmentally in is particularly true for brand-new group members; your own mind before commenting on the be- for individuals with known social anxiety disorder havior. (social phobia); or at times for individuals who have 2. Practice radical acceptance of clients who en- asserted skillfully that they are willful now, intend gage in repetitively annoying behaviors, but to be willful throughout the group, and clearly are who are corrigible if you make the effort. sticking to their guns. Some effort to engage such 3. Practice opposite action with a matter-of-fact clients may be useful, but excessive efforts may or light tone of voice when you want to with- backfire. If necessary, skills trainers can meet with draw. distressed clients during break or after sessions to 4. Practice opposite action, using irreverence or discuss and problem-solve the clients’ dysregulated humor with a light tone of voice, to avoid at- or interfering behaviors.  4. Skills Training Treatment Targets and Procedures 65 Priority 3: ing sessions. Skills trainers matter-of-­factly suggest Reducing Therapy-­Interfering Behaviors their use when appropriate. The key point here is that if skills trainers allow skills training sessions Behaviors that interfere with therapy, but do not de- to become focused on the therapy process or on cli- stroy it, are not ordinarily addressed systematically ents’ life crises—­including suicidal behaviors and in skills training. This decision is based primarily on quality-of-life-­interfering behaviors—then training the fact that if therapy-­interfering behaviors were a in skills will be forfeited. high-­priority treatment target for individuals with As I have discussed in Chapter 3 of this manu- high emotion dysregulation, trainers might never al, there is a wind-down period at the end of each get around to the designated skills training. Skills skills training session. This is an appropriate time training does not address the therapy process itself, to observe therapy-­ interfering behaviors or, even except as an avenue for teaching and practicing the more importantly, improvement in previous inter- skills being taught. When therapy-­ interfering be- fering behaviors. As long as everyone gets a chance haviors are occurring, effective strategies are (1) to to voice an observation, this time can be used as ignore the behavior, if it is brief; or (2) in a matter- therapy process time. One of the advantages of an of-fact but firm tone, ask the client to stop the be- observing wind-down is that it provides a time and havior and then resolutely focus (no matter what) place for discussing behaviors that are interfering on teaching the skills in the module at hand. This with therapy. (Cautions about process-­ observing is almost always the strategy employed with the less wind-downs have also been discussed in Chapter 3.) serious therapy-­ interfering behaviors. Sometimes these behaviors offer a particularly good opportu- nity for practicing the skills currently being taught. Skills Training Procedures: At most, these behaviors are commented on in a way How to Meet Skills Training Targets that communicates the desirability of change, while at the same time letting the client know that very lit- During skills training, and more generally through- tle time can be devoted to problems unrelated to the out DBT, skills trainers and clients’ individual treat- skills being taught. Thus mood-­dependent passivity, ment providers must insist at every opportunity that restlessness, pacing around the room, doodling, sit- clients actively engage in the acquisition and prac- ting in odd positions, attempts to discuss the week’s tice of skills needed to cope with life as it is. In other crisis, oversensitivity to criticism, or anger at other words, they must directly, forcefully, and repeatedly clients will be ignored at times. The client is treated challenge the passive problem-­solving style of indi- (ingeniously, at times) as if he or she is not engaging viduals with emotion dysregulation. The procedures in the dysfunctional behaviors. described below are applied by every DBT provider At other times, a skills trainer may instruct or across all modes of treatment where appropriate. urge such a client to try to apply behavioral skills to They are applied in a formal way in the structured the problem at hand. For example, a client who gets skills training modules. angry and threatens to leave may be instructed to try There are three types of skills training proce- to practice distress tolerance skills or the emotion dures. Each type focuses on one of the Priority 2 tar- regulation skill of opposite action (i.e., acting oppo- get behaviors: (1) skill acquisition (e.g., instructions, site to the action urge of anger). A client who is re- modeling); (2) skill strengthening (e.g., behavioral fusing to participate may be asked whether he or she rehearsal, feedback); and (3) skill generalization is being willful. If the response is “yes,” the trainer (e.g., homework assignments and homework review, may ask whether the client is willing to practice the discussion of similarities and differences in situa- skill of willingness. I often ask, “Any idea of when tions). In skill acquisition, a trainer is teaching new you will be willing to practice willingness?” A client behaviors. In skill strengthening and generalization, who is withdrawn and dissociating may be urged the trainer is trying both to fine-tune skilled behav- to practice crisis survival skills (e.g., cold gel pack iors and to increase the probability that the person across the eyes, paced breathing). In our groups, we will use the skilled behaviors already in his or her keep a number of rubber balls with spikes, a balance repertoire in relevant situations. Skill strengthening board, and cold gel packs available for use by people and skill generalization, in turn, require the appli- who are in danger of dissociating during skills train- cation of contingency procedures, exposure, and/or