This chapter discusses the application of structural strategies and skills training procedures to psychosocial skills training (Yeah, I know, it’s a bit heavy going but I’ll try to make it as easy to understand as I can.)
To start with, the author, Marsha Linehan, discusses strategies within the context of DBT.
A strategy can be defined as a plan of action designed to achieve an overall goal or aim. The author describes them as co-ordinated activities, tactics and procedures that a therapist can use to achieve a treatment goal (for example, learning a behaviour), but the word can also be used to describe the role and the focus of the therapist, and any responses a therapist might give to a particular problem. In DBT, strategies can be placed into one of five groups;
- Dialectical strategies
- Core strategies (Problem solving and validation)
- Stylistic strategies (These describe interpersonal and communication skills)
- Case management strategies (These describe how a therapist will respond to the individual circumstances of each client)
- Intergrative strategies (These provide options for dealing with the normal situations related to Borderlines, such as suicidal ideation, self harm episodes, problems with the relationship between the client and therapy, known as the ‘therapeutic relationship)
- Structual strategies (A sub-unit of intergrative strategies) (Involve the structure of time spent in therapy)
The author goes on to explain that within DBT, there are four sets of ‘change’ procedures used to model behaviour;
- Skills training
- Exposure-based (How to manage the exposure to potential triggers)
- Cognitive modification (Dealing with incorrect and maladaptive though patterns)
Following on, the author goes in to a lot more depth about structural strategies. These are important because they discuss the layout and time distribution of the treatment session, how it should be started and how it should be ended. I know from my own experience that I can be left feeling almost suicidal if a ‘session’ with a therapist hasn’t ended well, even if nothing obvious has happened. I personally think it is very important to have a form of ‘de-brief’ at the end of a session. There are five sets of structural strategies;
- Contracting strategies (There are six of these; 1) Conducting a pre-treatment assessment – this finds out the individual needs of the client and whether the therapy would be suitable for them, and whether it would be appropriate to invite them to the group. This time can also be used to gain commitment from the client to the therapy); 2) Presenting the bio-social theory of BPD which I have previously discussed here; 3) Giving the client an overview of skills training and its rationale – what is expecting of them and what they should expect; 4) Gaining a public commitment to therapy (proven to be more effective than a private commitment); 5) Assessing the client to find specific skill defecits & 6) Beginning to develop a therapeutic relationship).
- Session beginning strategies (Already discussed here)
- Session ending strategies (Already discussed here)
- Terminating strategies (Will be discussed in a later chapter)
- Targeting strategies (Deal with how time is used during skills training)
Within DBT, there is something known as a ‘hierarchical organisation of treatment targets’ which basically means that certain things, or issues, are more important than others, and should be dealt with in order of importance. In skills training, the targets are as follows, in order of importance;
1) Stopping behaviours likely to destroy therapy (Behaviours that would not allow therapy to continue, such as violence, serious verbal attacks, self harming behaviours, threatening suicide (in a credible manner), yelling and screaming. The miminum of intervention should occur to allow skills training to continue – the case should then be passed over to the individual therapist to deal with).
2) Skill acquisition, strengthening & generalisation (Most of the time should be devoted to this target.
3) Reducing therapy-interfering behaviours (These, as you can see, are of lesser importance that number 2). That is because they do not stop therapy from continuing, and most therapists find the best option is to ignore them. This includes behaviours such as restlessless, pacing, doodling, anger, attempts to discuss current crisis’.
The author then briefly discusses skills training targets and diary cards, and gives an example of a diary card that could be used; (Copyright Marsha M. Linehan but permission has been given for reproduction)
This can be used to track the progress of a client (with regards to practicing the skills learnt in the session) through the week between sessions. One side (the bottom of the picture) lists the skills which are taught and gives a place to show if they have been practiced.
So, following on from number 2) above, the author goes on to talk about the procedures involved in skills training. She describes that there are three types of skills training procedures;
- Skill acquisition (the teaching of new behaviours through instructions [verbal or visual descriptions of the behavioural response required] and modeling [providing an example of an appropriate behaviour through role play, self talk and instruction, videos, printed material, telling stories and giving examples, even the disclosure of the therapists own experiences.] It is important to note that if modelling is carried out outside of the group therapy, the therapist must be sure that the client is modelling their behaviour on someone appropriate]).
- Skill strengthening (This is fine-tuning the skills and increasing the likelyhood that they will be used by the client. To make sure a client learns a skill, they must PRACTICE, PRACTICE, PRACTICE! This can be achieved through behavioural rehearsal [a procedure where a client practices skills, and can either be ‘overt’ (out in the open such as role-play) or ‘covert’ (practicing in imagination)]. It is also useful to practice relaxation to teach the clients to control their psyiological responses such as anxiety, as well as their psychological ones. Clients can also be asked to practice ‘components of emotions’ such as changing facial expressions or muscle tension – this can help with learning to regulate emotions. Skill strengthening can also be practiced through response re-inforcement – giving positive feedback to the client if they have achieved the treatment goal of learning and putting into practice a skill. Borderlines are sensitive to negative feedback so it is important to be aware of that. Coaching can also be used, which is the combination of feedback and instructions.
- Skill generalisation (It is really important to make sure that clients are able to transfer the skills they have learned in sessions to everday situations. This is the primary role of the individual therapist but many people with BPD do not have the luxury of two therapists. There are several things that can help however, such as videoing the sessions and reviewing them, homework assignments to practice skills and a discussion about creating a ‘home environment’ which will support and re-inforce skilled behaviour – being surrounded by people who understand and have some knowledge of the therapy or removing potential triggers such as alcohol or drugs.
The following are general handouts which give information about skills training;
OK Guys so that’s pretty much for that chapter, well done if you got all the way through! Hopefully you found it useful, it certainly helped me to understand it by writing it out, even if I had to go through it paragraph by paragraph as it is a little heavy going in places!
Anyway, if you have any questions, any comments (or any criticisms – this is my understanding of what I have read but I may have mis-interpreted) then please let me know.
Take care. xxx