First!! Also, reflections on my first DBT group.
Starting this blog has been a bit of a struggle. Torn between wanting to make a grand first impression and simply getting things started I began to resign myself to inaction. This only intensified the pressure to produce, which is ironic because this blog was envisioned as a relaxed space where I could practice writing. I’ve finished rough drafts of at least 4 posts but I didn’t see them as being spontaneous enough or “worth the read”. Not wanting to contribute to the endless wasteland of Internet writing or clog up anyone’s “to-read” list with lack-luster information I’ve held off on posting anything. Which leads me to this, my first post. I recently finished my first Dialectical Behavioral Therapy (DBT) group and I feel that I finally have something worthwhile to share.
First off, a bit of context for this post is likely in order. I just finished my third year in the Clinical-Community Psychology PhD program at the University of Illinois at Urbana Champaign (UIUC). This DBT group was my first real foray into therapy or treatment with my previous experience being rooted in research and neuropsychological testing. The group consisted of teen-guardian dyads and was led by a co-facilitator (a more senior PhD student here at UIUC) and me. What follows is a list of things that I learned during and from this group. Many, if not all, of the points made below may be obvious to others, especially those more versed in therapy. If this is true, I hope this post gives a glimpse into where us “newbie” therapists start off and facilitates better training or coordination. For those just starting off in providing therapy I’m hoping that this will give you solace that someone has been there too, and some idea of what others have found useful.
In no specific order:
Prepare, prepare, prepare, and then throw it all out. Given that DBT groups are focused on skills training I had conceptualized the structure as similar to teaching — lay out a lesson plan, follow it as best as possible making space for unforeseen topics or issues, repeat till finished. What I quickly learned, however, is that group is all about knowing your material (preparation), creating a “best case” plan (preparation), having some contingencies (preparation), and then being willing to throw everything out the window and play it by the seat of your pants.
My co-facilitator and I spent hours across multiple days, and sometimes weeks, planning a group session. Then, only two of our dyads would show, or dyads would arrive halfway through a session, or we would need to have one-on-one sessions with individuals — taking them and the co-facilitator out of the picture for an indeterminate amount of time. Now, yes, as you gain experience and understand the group you begin to plan for these things. You make contingency plans. The problem is that the core of DBT is right; there is no constant but change. No matter your plans thing will go astray, and that’s fine. Some of the best and “realist” moments in our group this year were off-the-cuff.
So, know your stuff and be willing to ride the waves.
Engaging/ fun sessions are key, but so is rapport and comfort. This is true for all groups, but may be especially true when working with teens — you have to keep people engaged and interested. Our groups were an hour and a half long and took place in the evening. This means that members had already been through a full day of school or work, and then had to come sit through what is quiet bluntly, another teaching session, and in our case one that was completely voluntary. Simply put, this just doesn’t sound fun. So, you have to make it fun, or at least engaging. We based our sessions off of the DBT Skills Manual for Adolescents, which offers a number of interactive “game plans” such as: sharing personal stories and eliciting feedback about skill use; role-plays to practice using skills and to see how not using skills can look; and quiz-like competitions based on skill use and general DBT knowledge. In our group, using these near the start was a no-go, they fell completely flat. People simply weren’t comfortable enough with each other. We eventually worked through this and were able to use the exercises to increase engagement, but it took awhile.
Looking back, I wish we had made a more concentrated effort to actively create the open and close-knit relations that seemed to naturally develop. Now, I fully believe you can’t force these types of relationships, but you can foster an environment where they grow. While we did spend time with introductions and “icebreakers” I think we could have spent more time with similar activities. As co-facilitators we I think we may have been a little too nervous and focused on getting to the “content” of the DBT group. A suggestion from one of our guardians near the end of the group is particularly interesting in this regard. They suggested having the group meet at a casual spot (e.g., park, coffee shop, restaurant) before the first group session. This would present some logistical hurdles (e.g., is the length pre-determined or is it open-ended, choosing a location taking into account financial limitations and dietary concerns, is this paid for by the members or the group, what happens if people don’t come or if they need to bring non-group members, etc.) but if the context allows for it I think it may be an interesting idea to look into. Regardless, engagement is key, but engagement is dependent on comfort.
Don’t rush into the “content”, do your best to create a safe space and allow members to build relationships.
Collaborate on or at least openly discuss your group’s timeline and format. Everyone has time constraints and this needs to be taken into consideration when developing your group. This is especially true when engaging in therapy — people already have enough going on and ideally therapy shouldn’t be seen as an extra burden. Our group’s timing was further complicated by the teen-guardian composition (i.e., two schedules) and the fact that we are a training facility (e.g., supervisor hours, facility hours, class / research commitments). To work within these constraints we openly collaborated with group members in developing our group.
The DBT Skills Manual for Adolescents laid out sessions that were two hours long and met once per week for 24 weeks. Simply put, this was not going to work for us. Our facility’s timeline was shorter and the parents and teens both agreed that this was simply too much of an investment. As a group we ended up deciding that hour and a half sessions, once per week, for 16 weeks was manageable. This required leaving out a wealth of material but it was worth it.
We also collaborated with members on the group format. We devoted the first 40 minutes to homework review, had a 10-minute break, and then discussed new material for the last 40 minutes. The manual’s sessions were roughly the same, just with longer time slots. The breaks were essential, and I highly recommend them, especially for teens. They allowed individual’s to relax and recharge with snacks, and to socialize. In fact, this is where we saw member’s truly start to connect and feel comfortable with each other.
Lastly, something that everyone agreed was beneficial was our “splitting” format. Specifically, guardians and teens were split-up for the 40-minute homework review and brought back together for the break and new skills portions. This allowed individual’s to be more open and to discuss unique challenges they may be facing. While we initially talked about switching up co-facilitators each week we ended up keep them static — one always being with the guardians and the other with the teens. This seemed to help rapport and comfort build more quickly, which was very helpful with our truncated timeline.
Without openly discussing and working with our members we would have put a much bigger burden on them, and therefore us as well. Group attendance and engagement would have been down and in the end the group might have dissolved. By being transparent about our needs as co-facilitators and attending to their needs we not only kept the group alive but fostered rapport and respect.
There is a ton of information — give them a helping hand! Lastly, DBT is overwhelming. There are a ton of skills, many of them can be challenging, and integrating skills together can be extremely hard to envision or do. While members are all asked to practice outside of group, and there is typically accountability for this (e.g., diary cards, homework review), practicing in session is key. Once you are able to, engage in skits and role-plays. Yes, they can be scary, but they are completely worth overcoming any fear. This is where you get to really see people work with the skills and demonstrate understanding. It also allows practice and provides an opportunity for individual’s to learn from each other. In addition to these live action practice sessions I recommend providing individuals with a “DBT skills cheat-sheet”. Learning and using the DBT skills is a life long pursuit and having a quick reference guide is extremely helpful. The one linked above is based on the manual we used and contains only the skills we discussed, feel free to riff of it as needed.
Well, thats it! Thanks for reading and please feel free to comment,share the post widely, or completely forget about everything you just read. I’m hoping to have something to post each month…we will see how that goes…
Originally published at michaelkruepke.com on June 6, 2015.