DBT Skills Training Teaching Guide

372 Pages·2015·3.01 MB·English

by  Marsha M. Linehan

© 2015 Marsha M. Linehan
Published by The Guilford Press
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ii
CONTENTS
Chapter 6: General Skills: Orientation and Analyzing Behavior
Chapter 7: Mindfulness Skills
Chapter 8: Interpersonal Effectiveness Skills
Chapter 9: Emotion Regulation Skills
Chapter 10: Distress Tolerance Skills

iii
PART II
Teaching Notes
for DBT Skills Modules
From DBT® Skills Training Manual, Second Edition, by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan.
Permission to photocopy this material is granted to purchasers of this book
for personal use only. (See page ii of this packet for details.)
Chapter 6
General Skills:
Orientation and Analyzing Behavior
There are two sets of general skills. The first set fo- specific goals listed on General Handout 1 and in
cuses on orientation to skills training, including a the teaching notes are general enough to cover most
handout on the biosocial theory of emotion dysreg- of what might be taught in the average group. Op-
ulation. The second set focuses on how to analyze tional goals are noted. Skills training guidelines, or
behavior so that a client can figure out the causes or rules, are presented and discussed along with skills
events that influence the behavior. This allows the training assumptions.
client to problem-solve how to change the behavior In the teaching notes, I have put a checkmark
or how to prevent it in the future. (9) next to material I almost always cover. If I
am in a huge rush, I may skip everything that is
not checked. In the handouts and worksheets (see
Orientation www.guilford.com/dbt-manual), I have put stars
() on the standard handouts I almost always use.
An orientation to skills training takes place during After the first orientation session, reorientation
the first session of a new skills group. The purposes may be reviewed with members, or abbreviated if
of this orientation are to introduce members to one there are no new members starting the group. Make
another and to the skills training leaders; to orient an effort not to skip it, as review can be useful to
members to the structural aspects of skills training remind participants of assumptions and guidelines,
(e.g., format, rules, meeting times); to orient them and it is a good time to discuss whether new guide-
to the leaders’ approach and goals; to sell the skills lines should be added. If there are new members,
as worth learning and likely to work; and to gener- leaders should try to get old members to conduct as
ate enthusiasm for learning and practicing the skills. much of the orientation as possible. In either case, if
This chapter provides an outline of topics to be orientation is concluded before the session ends and
covered, but their content can be easily modified to the optional handouts are not being taught, leaders
reflect your particular circumstances (e.g., format, should proceed to the material for the core mindful-
timing, fees, rules, use of the telephone). An option- ness skills in Chapter 7.
al section for teaching the biosocial theory of how
emotion dysregulation develops is included.
Diary Cards
As discussed in Chapter 4, orienting is a skills
trainer’s chief means of selling the skills to group Diary cards (see Figure 4.1 in Chapter 4) provide
members. Therefore, important tasks for skills spaces for logging practice of all relevant skills.
trainers are to highlight the usefulness of the skills, These are usually introduced and reviewed by a cli-
to elicit participants’ specific personal goals, and ent’s individual DBT therapist. However, clients who
then to link these goals to the skills modules. Spe- are not in DBT individual treatment should be intro-
cific goals for the skills training you are conducting duced to the diary card in the orientation session. If
will depend on the skills that you plan to teach. The the diary card, which includes use of skills, is not
Thanks to Anita Lungu, Debra Safer, Christy Telch, and Eunice Chen.
125
From DBT® Skills Training Manual, Second Edition, by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan.
Permission to photocopy this material is granted to purchasers of this book
for personal use only. (See page ii of this packet for details.)
t II. TEACHING NOTES FOR DBT SKILLS MODULES
being reviewed by a participant’s individual thera- Chain Analysis
pist, the skills portion of the card can be reviewed
Conducting chain analyses of problem behaviors is
weekly as part of the homework practice review, in
a critical part of DBT. There are many ways to teach
addition to any assigned skills practice worksheets.
clients how to do this, and there are many places
If only the previous week’s homework is reviewed,
and times to teach it in the course of therapy. In
there is a danger that skills taught previously will
standard DBT treatment programs, individual ther-
drop off the client’s radar and not be practiced.
apists teach their clients how to do a chain analysis
in the course of individual therapy. DBT treatment
Biosocial Theory teams employ abbreviated chain analyses to assess
team- interfering behaviors of team members. In my
The biosocial theory is often reviewed in individual
treatment teams, we always do a brief chain analysis
DBT sessions, and in some programs it is taught in
with individuals who are late for team meetings. It
adolescent and multifamily skills programs. The
is often taught in residential and inpatient treatment
theory is particularly relevant for individuals meet-
programs. It is an important part of skills training
ing criteria for BPD and for individuals with perva-
1
for eating disorders and can also be very useful in
sive emotion dysregulation. It is important, if you
substance use disorder programs. When participants
are treating another population, such as one with
are not in individual therapy, teaching chain analy-
emotion overcontrol or other disorders, that you
sis can be incorporated into skills training when
teach a biosocial theory appropriate to the popula-
there is time and it appears useful. Inclusion of the
tion you are treating. The idea that all behavior is a
chain analyses in skills training per se is optional.
joint product of biology and environment, however,
applies to everyone. If group members or individual
therapists have reviewed this theory, there may be
Missing-Links Analysis
little to gain by reviewing it again.
Whereas a chain analysis breaks down problem be-
haviors, missing-links analysis is used to identify ef-
Analyzing Behavior fective behaviors that are missing. It consists of a
systematic set of questions and was originally de-
Because many DBT therapists teach their clients veloped for therapists to conduct rapid assessments
how to conduct their own analysis of problematic of failures to do assigned skills homework in group
behaviors, I have added a supplementary set of skills settings, where there is often limited time to review
that teach participants how to analyze and problem- homework. When missing-links analysis was used
solve dysfunctional ineffective behaviors (“chain for homework review in adolescent multifamily
analyses”) and how to identify effective behaviors skills groups, parents immediately wanted to learn
that are needed but missing (“missing-links analy- how to do it to analyze their children’s missing effec-
ses”). The chain analysis has been widely used in tive behaviors. Teens also wanted to use it to analyze
DBT. I developed the missing-links analysis at the their parents’ missing behaviors. From there, it be-
request of both adolescents and parents in our mul- came clear that it could be a useful strategic set of
tifamily group. questions for any missing effective behavior.
From DBT® Skills Training Manual, Second Edition, by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan.
Permission to photocopy this material is granted to purchasers of this book
for personal use only. (See page ii of this packet for details.)
6 . General Skills: General Handouts 1–1a t
Teaching Notes
I. THE GOALS OF SKILLS TRAINING (GENERAL HANDOUTS 1–1A)
Main Point: The overall goal of DBT skills training is to help individuals change behavioral, emotional,
thinking, and interpersonal patterns associated with problems in living.
General Handout 1: Goals of Skills Training. Use this handout to get clients to think about how
they could personally beneft from skills training, to identify which areas they are most interested in,
and to identify specifc personal goals of behaviors to increase and decrease in their own skills training.
For clients who have taken other skills training modules and been through orientation before, this is an
opportunity to evaluate the progress they have made on their personal goals since the beginning of the
previous module. The idea is to generate some enthusiasm for learning and practicing the skills.
Research on DBT is moving very fast, and data suggest that DBT skills training may be effective for a
large variety of goals. If General Handout 1 does not ft the goals of your group or individual client, feel
free to adapt or develop an entirely new list of goals for your client(s).
General Handout 1a: Options for Solving Any Problem (Optional). This optional handout can be
used at the start of a skills module, or it can be used at another point when you believe it would be use-
ful. The handout was designed as a reply to participants who responded to offers of help in solving life’s
problems with a “Yes, but . . . ” attitude. It can be particularly helpful to review this handout in those
situations. This handout describes the three effective responses to any problem and shows what catego-
ries of skills are needed for each. It also serves as a reminder that the only response that needs no skillful
behavior is the last option: “Stay miserable.”
General Worksheet 1: Pros and Cons of Using Skills (Optional). This optional worksheet is designed
to help participants decide whether they have anything to gain from practicing their DBT skills. It is par-
ticularly useful when they are feeling willful or apathetic and don’t want to practice. It can be reviewed
rather quickly if participants already know how to fll out a pros-and-cons worksheet. If not, review the
principles of doing pros and cons. Be sure to instruct participants to fll out pros and cons for both the
option of practicing skills and the option of not practicing. It can be useful, if there is time, to have par-
ticipants fll this out at least partially during the sessions. Suggest that participants carry the sheet with
them or post it somewhere at home, so they can easily review it as needed.
A. Introductions
To ease into a first session for newcomers, you can try going around the room and asking members
to give their names, tell how they heard about the group, and provide any other information they
would like to share. As the group leaders, you should also give information about yourselves and
how you came to lead the group.
B. General Goal of Skills Training
The overall goal of skills training is to learn skills for changing unwanted behaviors, emotions,
thinking, and events that cause misery and distress.
9C. Behaviors to Decrease
Ask participants to read General Handout 1 and check each set of behaviors they would like to
decrease. If there is a behavior on a particular list they do not have trouble with, they can cross it
out. Alternatively, they can circle the behaviors they think are most important to decrease.
From DBT® Skills Training Manual, Second Edition, by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan.
Permission to photocopy this material is granted to purchasers of this book
for personal use only. (See page ii of this packet for details.)
t II. TEACHING NOTES FOR DBT SKILLS MODULES: General Handout 1
Discussion Point: Discuss and share what is checked and circled. Ask participants to fll out per-
sonal goals at the bottom of the page. Discuss and share personal goals, including behaviors to
decrease and skills to increase.
Note to Leaders: The goals below are organized frst by specifc module and include supplemental skills
that you may or may not be teaching. You can skip describing and discussing supplemental skills if you
are not teaching them. In general, these notes are guidelines and should be adapted as needed to ft the
specifc skills you plan to teach and the characteristics of the people you are working with.
9D. Skills to Increase
9 1. Mindfulness Skills
Mindfulness skills help us focus attention on the present moment, noticing both what is going
on within ourselves and what is going on outside of ourselves and become and stay centered.
Mindfulness as a practice has now become widespread, with courses taught in corporations,
medical schools, and many other settings.
Present the mindfulness goals by types of skills you are teaching:
„ Core mindfulness skills (the mindfulness “what” and “how” skills) teach us how to ob-
serve and experience reality as it is, to be less judgmental, and to live in the moment with
effectiveness.
„ (Supplemental) Mindfulness skills from a spiritual perspective (including wise mind from a
spiritual perspective and practicing loving kindness) focus on experiencing ultimate reality,
forming an intimate connection with the entire universe, and developing a sense of freedom.
„ (Supplemental) Skillful means: Balancing doing mind and being mind
„ (Supplemental) Wise mind by walking the middle path
Discussion Point: Discuss goals of mindfulness skills training. Get feedback about individual goals.
Ask participants to write down their individual goals on General Handout 1.
9 2. Interpersonal Effectiveness Skills
Interpersonal effectiveness skills help us maintain and improve relationships both with people
we are close to and with strangers.
Present the interpersonal effectiveness goals by types of skills you are teaching:
„ Core interpersonal effectiveness skills teach us how to deal with conflict situations, to get
what we want and need, and to say no to unwanted requests and demands—all this in a way
that maintains our self-r espect and others’ liking and respect for us.
„ (Supplemental) Building relationships and ending destructive relationships. These skills
enable us to find potential friends, get people to like us, and maintain positive relationships
with others. They also show how to build closeness with others on the one hand, and how
to end destructive relationships on the other.
„ (Supplemental) Walking the middle path. These skills help us to walk a middle path in our
relationships, balancing acceptance with change in ourselves and in our relationships with
others.
Discussion Point: Discuss goals of interpersonal effectiveness skills training. Get feedback about
individual goals. Ask participants to write down their individual goals on General Handout 1.
9 3. Emotion Regulation Skills
Emotion regulation includes enhancing control of emotions, even though complete emotional
control cannot be achieved. To a certain extent we are who we are, and emotionality is part of
us. But we can get more control and perhaps learn to modulate some emotions.
From DBT® Skills Training Manual, Second Edition, by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan.
Permission to photocopy this material is granted to purchasers of this book
for personal use only. (See page ii of this packet for details.)
6 . General Skills: General Handouts 1–1a t
Present the emotion regulation goals by types of skills you are teaching:
„ Understanding and naming emotions: These skills enable us to understand emotions in
general and understand and identify our own emotions.
„ Changing emotional responses: These skills help us to reduce the intensity of painful or un-
wanted emotions (anger, sadness, shame, etc.), and to change situations that prompt painful
or unwanted emotions.
„ Reducing vulnerability to emotion mind: These skills enable us to reduce vulnerability to
becoming extremely or painfully emotional, and to increase emotional resilience.
„ Managing really difficult emotions: These skills help us to accept ongoing emotions and to
manage extreme emotions.
Discussion Point: Discuss goals of emotion regulation skills training. Get feedback about indi-
vidual goals. Ask participants to write down their individual goals on General Handout 1.
9 4. Distress Tolerance Skills
Distress tolerance is the ability to tolerate and survive crisis situations without making things
worse. Also, these skills teach us how to accept and fully enter into a life that may not be the life
we hoped for or want.
Present the distress tolerance goals by types of skills you are teaching:
„ Crisis survival skills: These skills enable us to tolerate painful events, urges, and emotions
when we cannot make things better right away.
„ Reality acceptance skills: These skills permit us to reduce suffering by accepting and living
a life that is not the life we want.
„ (Supplemental) Skills when the crisis is addiction: These skills enable us to back down from
addiction and live a life of abstinence.
Discussion Point: Discuss goals of distress tolerance skills training. Get feedback about individual
goals. Ask participants to write down their individual goals on General Handout 1.
5. Analyzing Behavior (Supplemental)
Present these skills if you intend to teach Sections VI and VII of general skills (see below).
„ Chain analysis and missing-links analysis are ways to figure out the causes of problem be-
haviors and plan for problem solving.
E. Format of Skills Training
1. Order and Length of Skills Modules
Review the order and length of skills modules, if this has not been discussed in a previous inter-
view. The specifics here will depend on the nature of your particular skills training program and
where in the cycle of modules the orientation session falls. (See also Chapter 3 of this manual.)
9 2. Session Format
Briefly review the overall session format: beginning ritual, review of skills practice since the last
session, break, presentation of new material, and a closing wind-down.
F. Options for Solving Any Problem
Note to Leaders: If the optional General Handout 1a is used at orientation, highlight the role of DBT
skills in each component of solving life’s problems. Remind participants of the options if at a future point
they reject all or most suggestions for solving a problem.
From DBT® Skills Training Manual, Second Edition, by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan.
Permission to photocopy this material is granted to purchasers of this book
for personal use only. (See page ii of this packet for details.)
t II. TEACHING NOTES FOR DBT SKILLS MODULES: General Handout 1a
Tell clients: “The options for responding to pain are limited. There may be an infinite number of really
painful things that can happen to you. But there are not an infinite number of responses you can make
to pain. In fact, if you sit back and think about it, there are only four things you can do when painful
problems come into your life: You can solve the problem, change your feelings about the problem, toler-
ate the problem, or just stay miserable (and perhaps even make it worse).”
1. Solve the Problem
Say to clients: “First, you can try finding a way to end or change the problem situation, or by
figuring out a way to avoid the situation or get out of it for good. This is the first thing you could
do—solve the problem.” Give these examples as needed:
Example: “If the distress comes from conflict in your marriage, one solution could be to avoid
spending time with your spouse; another solution could be to get a divorce and leave the re-
lationship; alternatively, you could get couple counseling and change the relationship so that
the conflict is resolved.”
Example: “If the problem is that you are afraid of flying, you could solve this by avoiding fly-
ing; alternatively, you could find a treatment program aimed at reducing fear of flying.”
Give these examples of skills that can help with problem solving:
„ Walking the middle path (from interpersonal effectiveness skills)
„ Problem-s olving skills (from emotion regulation skills)
2. Feel Better about the Problem
Tell clients: “A second way of responding to pain is by changing your emotional responses to
it. You could work at regulating your emotional response to the problem or figure out a way to
make a negative into a positive.” Give these examples as needed:
Example: “Remind yourself that conflict is a normal part of marriage and that it is nothing
really to be distressed about. Alternatively, develop more positive relationships outside of your
marriage, so that the negative aspects of conflict with you partner are not very important.”
Example: “Work on feeling better about having a fear of flying; alternatively, join a phobia
support group.”
Give these examples of skills that can help with feeling better about the problem:
„ Emotion regulation skills
„ Mindfulness skills
3. Tolerate the Problem
Say to clients: “When you can’t solve the problem that is generating distress and you can’t feel
better about it, you can still alleviate some of the distress.” Give these examples as needed:
Example: “In a marriage full of conflict, you might not be able to solve the problem through
divorce or by improving the relationship. You might also not succeed in feeling better about
the problem. But you will be less distressed and miserable about it if you practice radical ac-
ceptance of the problem.”
Example: “If you simply cannot get rid of your flying phobia and also can find no way to like
it or feel good about it, then you can reduce the suffering it causes you by radically accepting
it: It is what it is.”
Give these examples of skills that can help with tolerating the problem:
„ Distress tolerance skills
„ Mindfulness skills
From DBT® Skills Training Manual, Second Edition, by Marsha M. Linehan. Copyright 2015 by Marsha M. Linehan.
Permission to photocopy this material is granted to purchasers of this book
for personal use only. (See page ii of this packet for details.)