Comprehensive DBT: Setting clients up for success with skills

Cristofer Chan (DBT Clinician and Inner Solutions' Associate Director of Operations) provides information on how to acquire, strengthen, and generalize DBT skill use. He also discusses how phone coaching can be used to generalize DBT skills.

Transcript

SPEAKER_00 0:04

Welcome to the Inner Solutions Podcast. I'm your host, Jessica Heil. I own and operate Inner Solutions, a private practice clinic located in Calgary, Canada. Inner Solutions seeks to understand and help our clients by providing empirically supported treatments and evidence-based practices with compassion and expertise. This podcast will provide you with information regarding complex psychological conditions as well as treatments that are available. And today, Christopher is going to be speaking with me about a topic that I think is really important as a comprehensive DBT program. We're going to be talking about the process of how we help our clients acquire skills, strengthen skills, and generalize skills, which is something that is unique to doing full high-fidelity DBT therapy compared to being in a therapy where you just learn the skills, but they don't necessarily help you learn how to be able to make those skills generalize in your life. So we're going to start by me asking Christopher to explain what do I mean by acquiring, strengthening, and generalizing skills. And then we'll talk at the end a little bit about what is the difference between DBT comprehensive therapy and how it ties in those three different strategies versus uh just learning the skills on their own. So, Christopher, I am curious, what would you say it means when we say that we are trying to help our clients acquire DBT skills?

SPEAKER_01 1:51

Yeah, thanks for asking that. So acquiring DBT skills is really about learning what skills are, when to use them, how to use them. Much of this happens in a comprehensive DBT program under skills training, which is that 24-week skills class that a person would take in comprehensive DBT. For example, if I were to learn some other kind of skill like riding a bike, it would be like learning what a bike is and how to use it, when to use it, understanding what makes it go and not fall over, and watching a parent use a bike and seeing that they can ride on a bike and stay upright.

SPEAKER_00 2:28

That makes a lot of sense. So it's really about figuring out kind of the basics first, like what am I doing and kind of like how am I going to do it?

SPEAKER_01 2:37

Yeah. So in the individual psychotherapy portion of this, it really starts with an assessment of the skills the person already has and any skills deficits that are present. In a skills training program, you would learn all the skills in DPT anyway, and the that your individual psychologist could then also tailor uh what you're learning in skills class to what's happening in your real life while you're seeing them individually as well.

SPEAKER_00 3:02

Okay, that makes sense. Can you speak a little bit to when you say skills deficit, what do you mean?

SPEAKER_01 3:08

Well, sometimes when people get into situations in real life, a lot of the times people will assume that the reason a person behaved in a certain way was because they didn't care enough about something or weren't trying hard enough to do something. And what DBT believes is that a lot of the times people just don't have the skill. They don't know how to act in that way. Or maybe they know how to act in that way in some circumstances, but in other contexts, that skill is not there. So identifying skills deficits is important for treatment planning because it allows us to make sure that those skills are acquired. And um, I just want to say a little thing about acquiring skills. It's not just about teaching. Uh, the three big components of skills acquisition is assessment. So that's that part again where I talked about trying to figure out what skills deficits and what skills are already there. The next part is instruction. So that's the learning, as I was talking about before, learning how to use the skills, what the skills are, and modeling. So actually, you know, seeing a person or your therapist or a skills trainer use the skills and seeing that they work. It's kind of like watching your parent on the bike, like I mentioned before.

SPEAKER_00 4:21

Yeah, I like that a lot. It's yeah, it's one thing to teach it by kind of sharing with a person like how to do it through verbal instruction, but a totally different thing to actually watch somebody use the skills and demonstrate the skills so that you know what they look like kind of in real time.

SPEAKER_01 4:37

Yes, absolutely.

SPEAKER_00 4:38

Yeah. And where would you generally see people learning the skills, acquiring the skills? Would you say in DBT therapy, is this happening in individual therapy? Is it happening in a skills class?

SPEAKER_01 4:50

I would say that it can happen in a variety of contexts. So for the most part, I think the most easy answer for me to give is during skills training, that skills class, because it is part of the program curriculum and you know you're going to get that skill as part of that curriculum. And it can also happen in individual psychotherapy if a skills deficit is there and a person could benefit from learning that skill before they end up encountering in the skills class as it's structured. I understand we might get into this a little bit later, but we also have this other piece of DBT called phone coaching. And there will be times where a client will reach out for phone coaching and a skill is uh taught in that moment because it is relevant for the situation.

SPEAKER_00 5:32

Yeah, so true. So there's really three different opportunities for our clients to be able to acquire skills when they're doing comprehensive DBT. It could be in individual therapy, it most certainly would be in DBT skills class, and it could be during phone coaching if they haven't actually heard of the skill before and it's something that is looking like it might be a benefit for them to use it right now, then we might actually just go ahead and teach them that skill in that phone coaching session, despite them having not encountered the skill before. Okay, so that makes sense to me in terms of what is acquiring skills and where our clients would get to acquire those skills. What does it mean when we say skill strengthening?

SPEAKER_01 6:11

Yeah, so skill strengthening is really about uh learning that we can actually do it and actually doing it ourselves. So I mentioned a little bit about how we might watch somebody, let's say in skills acquisition, we might see an example in skills class or or we'll do some role playing with our therapist to see our therapist use a skill. In this case, we might be doing some role play so that we can use a skill. I I think of it as like when you're learning to ride a bike and you're actually getting on the bike yourself and you are your parents are watching you and encouraging you, cheerleading you without judging you for being scared or assuming you're not trying hard enough. So skill strengthening really is about actually doing it yourself. Sometimes we involve imaginal practice. So I might practice the skill in my head before I actually do it in real life, just so I can get some practice in in terms of like a situation I have in my life that isn't in the therapy room. And I mentioned before the feedback and coaching and reinforcement. So our individual therapists would reinforce us and, you know, give us some of that cheerleading as well as coaching and feedback without that judgment of, you know, you need to try harder, you're not willing to do it, why can't you just care more? You know, which is something that a lot of people hear from their environment and we want to get away from that.

SPEAKER_00 7:35

Yeah, so true. And I I think back to something you said at the beginning of this episode around when I asked you about skill deficit, and and you had said that sometimes the yeah, this the skills just is just not there, but it can sometimes show up at times, but not others. And that kind of I find that that loops back into what you just said here, that that's where it gets so tough for the environment because on occasion, our clients might be able to produce a certain behavior because kind of the stars and the moon align, and it's that like the vulnerabilities around what makes a behavior harder, maybe just a little bit lower in that moment, but then in a whole different environment, they're they're just not able to produce it in the same way. So then the environment goes, Well, I've seen you do this before. Why did you do this before? But you can't do it now. And that can lead to that form of invalidation because oftentimes our clients actually don't know why they're not able to produce it in certain environments versus others. The skill strengthening, I think, is so important because at least then it gives them the opportunity to practice the skill in sort of a contained environment before having to figure out how to. Now I'm getting ahead of ourselves, but how to generalize the skills in all environments.

SPEAKER_01 8:48

Yeah, absolutely. So essentially, like, I mean, I don't know how old you were when, you know, Jessica, do you do you know how to ride a bike?

SPEAKER_00 8:56

I do know how to ride a bike, yeah. I do.

SPEAKER_01 8:59

Yeah, yeah. So I don't know how old you were, but I was, I was just a little kid. And I know that I needed to actually get on a bike to actually be able to really know that I could do it. It just looks, it looks so, you know, natural seeing someone else do it. And then I get on it and I'm like, oh my gosh, my bike is leaning immediately to to one side and I might fall off. And so in skill strengthening, that's me actually getting on a bike and I'm actually pedaling and oh my gosh, I can do it. That does not mean that I'm gonna go on a giant hill and be able to stop.

SPEAKER_00 9:33

I love that because yeah, we need to learn how to ride the bike on like smooth pavement with no bumps, and we're not going down a hill or up a hill, and there's no rocks or anything first before being able to go off and do those more complicated rides.

SPEAKER_01 9:47

Absolutely.

SPEAKER_00 9:48

I think about some of the examples of just different times I've been with my clients where I've seen how important skill strengthening is. A lot of people will think that they've got the skills kind of nailed down because they know, again, how to explain the skills. Like they can walk through the skills and tell us exactly what they should look like. But then when they're actually trying to embody the skill, what often gets produced is is not quite what would be effective if they were to do it like outside of therapy walls. The big one that I think about is with our dear man skill, which in DBT, Deer Man is a script that we use to help people learn how to be assertive so that they're more likely to get their needs met by others. And oftentimes people can describe what assertiveness is. They know the acronym of the deer man, they could tell you exactly which at what every step is. But then when you get them to actually produce a deer man in session, like I'll say to them, okay, like pretend like I'm whoever, right? Like I'm your I'm your I'm your spouse and you're going to do a deer man on me. Then, like, how would you do it if I was your spouse? And then what ends up coming out of their mouths isn't necessarily what would be the most effective in a conversation. And then that gives me an opportunity to be like, oh, I see what's going on here. We were able to explain the situation and maybe express how you felt, but you never asked actually asked me for what you need. And so if I can give them that coaching on that one part and be like, hey, like now we need to figure out not only about not expressing what we don't want, but we need to figure out how to ask what we do want. Sometimes that can be such a light bulb moment for people because they're like, oh, that's what's been going awry in my conversations.

SPEAKER_01 11:26

Yeah, absolutely. I think that, especially with the dear man skill, it's one of those skills that, you know, when you become quite proficient at using the skill, you may be able to pull one out of your pocket and deliver one with ease. And that's actually one of those skills that I usually recommend people rehearse beforehand. When you are trying to be assertive with a certain situation in your life, many times you are aware of it beforehand. I want to ask my boss for a raise, I want to ask my parents for this, I want to ask my partner for that. And actually rehearsing beforehand can be really helpful in delivering that because a lot of the times deer men situations are very specific and they can be isolated situations. So part of that skills strengthening does also include some of that imaginal rehearsal. So I'm actually going to imagine myself saying this to the person. I'm going to role-play with my therapist as well. So that way when I get to the actual situation, I am more equipped to deliver that effectively.

SPEAKER_00 12:25

Absolutely. Yeah, being able to get at it through those visualization pathways in our brain, but also through the actual experience of having practiced. And both will end up strengthening that skill or or any other skill. Like right now, we're talking just about deer man, but we could extend this conversation to any of the DBT skills. The more that we practice them, the stronger that skill is going to show up for us when we really need it.

SPEAKER_01 12:48

Absolutely.

SPEAKER_00 12:49

Yeah. I'm going to, I want to take a little bit of a segue here. And I want to ask you a question that's going to seem a little bit off the beaten path, but uh, but it I think it does pertain to this next next piece. And you had already alluded to it. Can you tell us a little bit about what phone coaching is?

SPEAKER_01 13:03

Yeah, absolutely. Phone coaching is it's part of a DBT comprehensive program. And really what it is, is it's the ability for the client to seek assistance in using skills in everyday life. So that might look like is like, for example, let's say I know how to use a skill because I've learned it in skills training. I have practiced it with my therapist. And I get to a situation where, unlike these other situations where I've had the chance to practice them, my emotions are really high. This is a skill I'm using with a person that has a history with me that's maybe a little bit contentious. And I'm having trouble thinking. I don't know what skill to use. I don't know how to use the skill. What do I do? Right. And those are a lot of the times when I think of like when you are biking down a bigger hill and it's your first time on a big hill and you're by yourself. And, you know, usually you'd know how to stop. And instead, you're hopping off the bike before, you know, it hits a fence because at that moment you couldn't think of what to do. And so phone coaching is really that ability to ask for some of that help, uh, assistance in knowing what skill to use in this moment, how to use it, assisting me in making sure I'm using the skill to the letter and uh getting that help in those real situations.

SPEAKER_00 14:21

Yeah, absolutely. Not having to wait until the next session to be able to figure out what to do, that you're able to contact your therapist or a DBT therapist and be able to get that kind of real-time coaching. It really is coaching on, okay, so I tried this skill. It didn't go the way I thought it was going to go. What else can I do? Or I just don't even know what skill to use. Like, what should I do? And then the therapist is like, okay, let's go try this, this, and this, give it a shot, get back to me, let me know how it went. And then we get to troubleshoot until we get the the hoped for results from that skill.

SPEAKER_01 14:55

Absolutely. I almost think of it as like the man in the chair for any of you fans out there of uh Marvel, Marvel films, the man in the chair of like, you know, hey, turn left here. Oh, you're, you know, hit the brakes now. Right. So just that extra help and support in that moment.

SPEAKER_00 15:11

Absolutely. Yeah. Yeah. I think that's uh it and it really goes a long way. I I see with our clients that when they're able to access that phone coaching, it just speeds up therapy so much because it's it can be the thing that just gets those skills to really click. And then it's like that aha moment. They all of a sudden know what to do and how to do it. And therapy will just propel forward in a way that I truly don't know that it would go forward in the same speed if phone coaching wasn't available. Definitely. Okay, so then let's talk about this last component of these strategies. We have acquiring skills, strengthening skills. Let's talk about now what it means to generalize the skill. And and you've kind of already alluded to it by talking about phone coaching. Phone coaching is one of those features of DBT that help us to generalize, but can you maybe just define generalization a little bit more first?

SPEAKER_01 16:04

Yeah, absolutely. So generalization really is about being able to apply these skills in real life situations across different situations and to have them be more automatic. I like to think of again that bike example of once I have been able to ride a bike for some time, I don't need to think as much about how to break. I'm just gonna break when I need to slow down or stop. Um, it becomes a lot more automatic, as well as you know, my confidence in being able to do so. I'm no longer as resistant to riding on those bigger hills or going on those bike rides with friends because I know that I can do it. So I've sort of developed that confidence as well. In skills generalization, really what happens in therapy is a lot of it happens with your individual therapist in terms of figuring out a program for generalizing skills to your actual life and in vivo rehearsal assignments for you to practice those skills in bigger situations. Sometimes this can also be touched on in skills training because in skills class, there are assignments given at the end of each week as well to practice skills. Sometimes these skills, the the practicing these skills for the home practice fit under skills strengthening. And uh when you're using them for situations that are a little bit bigger over time, that can also work towards skills generalization as well.

SPEAKER_00 17:26

I like that. So, again, lots of opportunities to be able to learn how to generalize those skills in DBT therapy. And and I love again the metaphor, right? Like it really is about being able to be kind of like versatile in how we're applying these skills, just like we would be on a bike, that we start on that smooth pavement and then with time and strengthening those skills, we're really going to be able to take on those bigger challenges, like maybe starting to go mountain biking and uh take on different terrain or different weather when we're biking and all sorts of things. And that's really the goal of being able to get so proficient with these skills that we can really just use them anywhere and everywhere, regardless of how we're feeling and who else is involved. We want these skills to show up for us in any environment, in any context, and feel confident that we're going to be able to produce that skill. Oh, yes, for sure. And I think about how having a therapist who knows how to help their clients generalize skills, I think this is really essential to DBT being successful. And I really do see this as the core difference between doing therapy with a therapist who might kind of like know of the skills and be able to teach the skills, like help them acquire it, versus doing a full comprehensive DBT therapy. The the piece about acquiring, strengthening, and generalizing, I've noticed seems to be something that is unique to DBT therapy and full fidelity therapy as a whole. And I do think that this is part of what builds up the success of clients who do comprehensive DBT, is that they're not only just like taught those skills, but they really are, there's such a huge focus on strengthening and generalizing those skills as well. I'm curious, as a DBT-trained clinician, what are some of the ways that you specifically help your clients generalize their skill use?

SPEAKER_01 19:13

Yeah, thanks for asking that, Jess, because I think that's so important. As a DBT trained clinician, um, one of the things I would do is I like to incorporate skills training and phone coaching into my individual therapy with my clients. So that means I check in on my clients and every session about how skills training is going and following up on phone coach use. And one thing that we do do in DBT is we approach skills training with kindness and validation while at the same time holding our clients' feet to the fire and following through. Sometimes that means problem solving when skills don't go as well as we'd hoped or when skills don't happen. If my clients are just, if I'm just teaching my client skills and just leaving it there, then there are a lot of opportunities for generalizing and strengthening those skills don't happen. And those are crucial for success in therapy. Um, another thing that we also do is we focus on two things. One of them is called response generalization, and the other is stimulus generalization. And what those mean is response generalization is having many options for a certain situation. I have this event or this uh circumstance, and I have a variety of skills I can choose to apply here. And I know those skills well enough to use them all here, and I can decide which one I want to use now. And then stimulus generalization is for each skill I have, they can actually be applied to a variety of things as well. And so I'm really working with my clients and programming that generalization so that there are multiple options for each situation, and each option can be used in a variety of places.

SPEAKER_00 20:52

Yeah, I love that. I think about another metaphor coming to my mind that we're really trying to equip our clients with a toolbox and it has many, many different tools, but they also know exactly what each tool does. So, like you said, there is a variety to choose from, but also an understanding of the application of each so that it doesn't look overwhelming when they look at all these tools.

SPEAKER_01 21:18

Yeah, this is where a DBT trained clinician really fits in here because it's more than just teaching people what the skills are and how to use them, right? It's that follow-up from beginning to end, from acquisition to strengthening to generalization. And essentially what we really want is for these skills to show up in real life, not just the things that we talk about and you know, check in. Oh, did you use that? You didn't? Okay. Try again next week, try again next week, try again next week. Actually following through so that it actually makes an impact in people's lives.

unknown 21:50

Yes.

SPEAKER_00 21:51

Yeah, exactly. Because that's how life is going to change so that eventually people are feeling like they are like DBT refers to living a life worth living. And that's that. follow through from the acquisition to the strengthening to the generalization is such a huge part on in terms of trying to get people to feel like life is going the way that they want it to. And I think that's probably a good place for us to stop today. I feel like we've we've given everyone lots to think about. So Christopher, I just want to say thank you so much for joining us today. I really appreciate it.

SPEAKER_01 22:20

Yeah, thanks, Jess, for having me. It was a pleasure being here.

SPEAKER_00 22:23

Perfect. And we will see everybody next episode. Thanks so much for listening. If you found today's episode helpful, please go ahead and leave us a review and you can also follow the show so that you don't miss out on any future episodes. For more information about us, you can check out our website www.innersolutions.ca