DBT For Dummies. Gillian Galen

a patient’s daily life. If the skills learned in therapy sessions don’t apply or transfer to patients’ daily lives, then it would be difficult to say that therapy was successful. This function is accomplished in two ways:

       In the skills training group, the therapist provides and then reviews the weekly homework assignments given in the skills group.

       The patient is allowed to contact the therapist between sessions so that they can get help directly from the therapist in situations where the patient doesn’t know what to do or how to apply the skills. (Find out more about phone coaching later in this chapter.)

      Supporting the therapist

      To be effective in the work they do, therapists delivering DBT treatment must stay motivated to work with patients, particularly those patients whose behaviors they find challenging. Many therapists find the work with patients who have BPD and related conditions to be very rewarding, while at the same time, their patients’ intense emotions and at times self-endangering behaviors can lead to therapist burnout and despair.

Therapists who provide DBT are required to sit on a consultation team, which is a group of other DBT therapists who meet on a weekly basis to help each other by using the same techniques that they use with their patients. Therapist burnout is essential to deal with and is applied by using consultation with the therapist, problem-solving, validation, and ongoing training and skill-building, as well as encouragement to persist in applying compassionate care. The typical consultation team meets once per week for one to two hours. We talk about consultation teams in more detail later in this chapter.

      Structuring the patient’s environment

      Structuring the environment, when necessary, in a way that maximizes the chance of success includes the use of reinforcement of adaptive behavior and not reinforcing maladaptive behavior. Structuring also includes helping patients modify their environment. For example, patients who use drugs might modify their circle of friends. People who use dating apps that have led to abusive relationships may be coached to delete the apps. Patients who struggle by staying up late at night might need to modify their nighttime routine to promote better sleep hygiene.

      Patients may need help in finding ways to modify their environments. Typically, the patient is coached as to how to make the modifications, but for younger or less skilled patients, the therapist may need to take a more active role in helping structure the environment. Get the scoop on structuring the environment in Chapter 16.

Checking Out Modes of Treatment

      How can the five essential functions in the preceding section be attained? There are four modes of treatment in the standard model of DBT to ensure that the treatment can be comprehensively applied. Not included in these four modes are other modes of treatment, such as medications and services like case management. These other modes can be added to DBT, and often; however, they aren’t core to the treatment.

      Skills training

      

The mode of treatment most frequently implemented in DBT is the skills group. There are various reasons for this. Pragmatically it’s easily implemented and structured. It can meet the needs of many patients because it teaches more than one patient at a time. It has a set curriculum, handouts, and homework, so it appears very much like a typical classroom setting. Further, many mental health settings don’t have enough DBT-trained staff to have every patient be assigned to an individual therapist, and in this context, a therapist working with a co-leader can, at a minimum, introduce a larger number of patients to the treatment. It’s important to note that there is strong evidence that the use of skills training alone is effective in helping patients with many of their mental health symptoms.

In this mode, patients focus on learning new skills in a classroom-like atmosphere. The skills are then enhanced through practice exercises, as well as generalized to other aspects of the patients’ personal lives by the assignment and review of homework. The specific skills that are taught are the four DBT skills modules: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. The modules are typically taught over six weeks, although this can vary, depending on the needs of the patients and how quickly they learn the material. The specific skills are reviewed in depth in Part 3.

      In a group meeting, the typical structure is once per week, lasting somewhere between two and two and a half hours. The first hour is devoted to a review of the homework assigned in the previous session, and the second hour is dedicated to the teaching of new skills. Homework is then assigned as the last task of the group.

      Note: There are certain circumstances when skills are taught in individual sessions. For instance, a person may have work limitations that don’t allow them to participate at a particular time, or they may have language limitations or learning disorders that don’t allow them to keep up with the pace of teaching in a large group.

      Individual therapy

      Individual treatment in standard DBT is conducted weekly or biweekly in 60-minute sessions, and it’s focused on understanding, exploring, and targeting the behaviors that a patient wants to change. It does so by keeping the patient motivated to complete the treatment and encouraging them to apply the new skills they have learned in the group. A variety of techniques, which are covered in Part 4, are used by the DBT therapist to address motivation when it has started to wane.

      Phone/skills coaching

      The skills of DBT are of little value unless they are put to use in the moment that they are needed. When times are calm and emotions are better regulated, it’s easy to see how the skills can be useful, and many patients can explain how the skills would work in their day-to-day life. However, in times of emotional turmoil, the more familiar, often maladaptive, behaviors are the ones that tend to show up first. When the urges to self-harm or use substances show up, the more intense the emotions, the more likely the unskilled person is to use these old forms of dealing with the urges.

Dr. Linehan recognized that life’s most challenging problems tended not to happen when patients were in therapy. They could happen at any time, day or night. She emphasized the importance of intersession coaching to help patients generalize the skills they had learned in the skills training group to their everyday life. The duration of a skills-coaching call is intended to be a brief call of typically no more than 15 minutes to offer patients support and ideas to deal with an in-the-moment situation.

      

One of the major concerns that new therapists worry about is that spending time out of session on the phone with their patients might reinforce life-threatening behavior. In other words, they worry that if patients feels supported during a call when they are feeling suicidal, it’s possible that they may then express more suicidal thoughts to be able to speak to their therapists more frequently. Therapists are taught how to deal with this eventuality (see Chapter 14).

      A therapist consultation team

      One of the more difficult aspects of working with suicidal patients is that it’s common for therapists to become discouraged and burned out. Dealing with suicidal people every day can make therapists feel much of the despair that their patients feel. Behavioral change can take time, and many therapists worry about their patients’ safety during episodes of emotional distress. The therapist consultation team is intended to be therapy for the therapists, supporting them in their work with patients who have