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If you utilize dialectical behavior therapy (DBT) in your clinical work, you already know that this modality can be extremely helpful to clients. In some cases, DBT literally saves lives. You may also be familiar with how it can be difficult for some clients to tolerate learning DBT concepts and skills.
When teaching DBT-informed skills groups, I have witnessed a range of reactions from clients exposed to this modality. While some become DBT lovers (like me), I have seen others groan or protest as I pass out handouts from the DBT Skills Training Handouts and Worksheets manual. (To better understand why some clients struggle to access DBT, see this post.)
“So I’m Supposed to Customize It?”
Marsha Linehan, author of the DBT Skills Training Manual, acknowledges the difficulties of teaching these skills. She understands the potential barriers and encourages facilitators to use whatever resources, strengths, and skills they have to customize the modality to best meet a client's needs. In her manual, she provides examples of creative ways to support clients. But at the same time, the process of “customization” can be confusing and overwhelming for many facilitators. They may be asking themselves:
- Is there guidance on best practices for modifying DBT so I can ensure that I am not decreasing treatment efficacy?
- How do I come up with creative exercises in my 10 minutes between sessions?
- How much time do I actually need to come up with these exercises or improve the ones I am already using?
- Will changing things improve engagement?
- I’m running a group… How can I customize the skills to benefit all of its members?
Following is what the literature says about improving engagement in skills training and interventions from action-based DBT.
1. Supportive Spaces
As therapists, we know that magic happens in cohesive, supportive groups. This applies to psychoeducation groups as well. Research indicates that a connected, supportive environment in DBT skills training can help individuals who are experiencing strong, unwanted emotions, particularly feelings of anxiety and shame. According to Barnicot and colleagues (2015), participants found learning much easier when there was a “fun, light-hearted atmosphere in the group." These researchers also illuminated how it is beneficial for all participants to feel included in the group process, even those less inclined to volunteer spontaneously.
Most therapists have had the experience of being in the following version of a psychoeducation group: A worksheet is passed out, the facilitator teaches, and then asks for feedback. The facilitator “calls on” certain group members if the room is silent. Group members do not respond to one another, and you can hear the crickets chirping.
Suppose you have participated in or facilitated one of these groups. Imagine the relief you may have felt when the session was over. As you left the group room, you may have asked yourself, "What just happened?”
One of the reasons that psychoeducation groups run in this format can feel a bit cringe is that group members likely feel disconnected from the content, facilitator, and each other. Finding ways for the participants to connect, perhaps by splitting members into dyads for conversations or engaging in an experiential mirroring exercise, can build cohesion. The research indicates that developing a sense of connection and community within a positive environment leads to better outcomes (Cancian et al., 2019). Finding ways to break up the group and create opportunities for connection between participants can greatly increase cohesion and shift the group from “When will this end?” to “We have so much more to discuss!” One pathway to generating a supportive space is helping group members connect with one another—a strategy that can shift the entire energy of the group.
2. Personalization
Personalizing skills for each group member may support participants in better understanding and internalizing information. You likely already know this, as it was a concept taught in graduate school. When teaching DBT skills, “leaders often have to be creative in demonstrating how particular sets of skills apply to particular problems” (Linehan, 2015).
Research emphasizes the personalization of skills and highlights that the understanding of each client's specific challenges is the first step toward personalization. This can be quite a challenge when managing an entire group of clients with varied skills and needs. That being said, prompting clients with directives that allow them to apply the skills to their own life is a great place to start.
If teaching the DEAR MAN skill, for example, use the client’s experience (not an example from a handout). If the clients are too overwhelmed to provide personal experiences with the group, encourage them to write one down or break the group into dyads so they can share with another individual. If that is still overwhelming, just have them write about a personal experience. Assess each of their unique struggles and try to pinpoint the precise triggers, behavior patterns, or emotions that need specific attention.
By tailoring the delivery of these skills to the individual needs and preferences of each client, you can greatly improve their engagement in the therapeutic process and overall results for everyone.
3. Creativity
The ability to foster a sense of creativity within your group can also strongly impact engagement in these settings. For example, give each participant a chance to think on their own before a group brainstorm. Research suggests that clients will come up with more creative ideas if they can respond to facilitator prompts independently before sharing them with others (D’Zurilla & Nezu, 1999; Paulus & Brown, 2007). In other words, it can be more effective to have the clients jot down ideas on their own and then bring the group together to brainstorm.
Linehan knew about the importance of getting creative with DBT, and the research has supported this. Cancian and colleagues (2019) suggested that experiential and creative exercises, particularly ones that included “stories, metaphors, and practical exercises,” facilitated client engagement and comprehension. Some creative arts therapists have found that psychoeducation groups are more effective when clinicians teach skills in creative ways (Clark, 2017; Heckwolf et al., 2014; Huckvale & Learmonth, 2009; Morris, 2018; von Daler & Schwanbeck, 2014; Walters, 2018; Roohan & Trottier, 2021). While going through the many ways creative interventions have been infused into DBT skills training is not within the scope of this page, I think it is essential to acknowledge that this work is happening.
References
Barnicot, K., Couldrey, L., Sandhu, S., & Priebe, S. (2015). Overcoming Barriers to Skills Training in Borderline Personality Disorder: A Qualitative Interview Study. PLOS One, 10(10).
Cancian, A. C. M., de Souza, L. S., & da Silva Oliveira, M. (2019). Qualitative analysis of a Dialectical Behavior Therapy adapted Skills Training group for women with obesity. Contextos Clínicos, 12(3), 707.
Clark, S. M. (2017). DBT-informed art therapy: Mindfulness, cognitive behavior therapy, and the creative process. Jessica Kingsley Publishers.
D’Zurilla, T. J., & Nezu, A. M. (1999). Problem- solving therapy: A social competence approach to clinical intervention (2nd ed.). New York: Springer.
Heckwolf, J. I., Bergland, M. C., & Mouratidis, M. (2014). Coordinating principles of art therapy and DBT. The Arts in Psychotherapy, 41(4), 329-335.
Huckvale, K., & Learmonth, M. (2009). A case example of art therapy in relation to dialectical behaviour therapy. International Journal of Art Therapy, 14(2), 52-63.
Linehan, M.M. (2015). DBT skills training manual (2nd ed.). Guilford Press.
Morris, N. (2018). Dramatherapy for borderline personality disorder: Empowering and nurturing people through creativity. Routledge.
Paulus, P. B., & Brown, V. R. (2007). Toward more creative and innovative group idea generation: A cognitive–social–motivational perspective of brainstorming. Social and Personality Psychology Compass, 1, 248–265.
Von Daler, K., and Schwanbeck, L. (2014). Creative mindfulness: Dialectical behavior therapy and expressive arts therapy. In L. Rappaport (Ed.), Mindfulness and the arts therapies: Theory and practice (pp. 107-116). Jessica Kingsley Publishers.
