This feature by Dr. Jim Lyng is Part 1 of 3 in a series about bringing a DBT Skills training group online during the time of the COVID-19 pandemic. In this part, we examine the need for this pivot before we take a further look at the particulars of how to be more effective in this transition in our upcoming part 2 and 3.
Somewhere towards the end of your training in DBT there was probably a point where you felt overwhelmed at the prospect of what lay ahead. It just all seemed so big. There was the task of learning this new therapy, as well as playing your part in implementing or sustaining DBT in your service setting, not to mention getting your mind around this strange new idea of a dialectical worldview. But if you think back, at this point in time there is also a good chance that you were getting a clear message from your DBT trainers which sounded a little like the Nike slogan: Just Do It.
Overthinking, too much planning, excessive caution – these understandable responses, your trainers told you, are enemies of getting DBT up and running. Certainly, they agreed that there are important strategic and clinical questions that need to be resolved before any DBT programme kicks off. Yet your trainers likely also pointed out that many a seasoned and successful DBT therapist, including themselves, have their war-stories of learning DBT on the hoof, book in hand, client or group in the room, taking one step at a time, using observation, feedback and measurable behavioural change as instructors.
If you reconstruct your journey of becoming a DBT therapist, there probably wasn’t a specific eureka moment when you realised you had just ‘got it’. At the same time, I suspect that if you hadn’t just jumped into the pool you’d probably still be sitting there on the edge, thinking and worrying and coming up with excuses, wondering what water felt like, instead of doing laps like it was your birthright.
Just Do It.
And so it is with the transition from bricks-and-mortar, in-person DBT to video-based DBT. Take the plunge.
For many of us video therapy may not be a forum or medium we would ever have chosen for our clients or service. Equally, many of our clients didn’t sign-up to have us video-call into their homes, Star Trek-style, with all of the new clinical dilemmas and practical challenges this poses. Yet here in the middle of this Covid-19-fuelled emergency, which increasingly looks like it will define much of at least the next calendar year, where staying apart from one another is literally a life-saver, in the same way that DBT is a life-saver, we find ourselves at an unfamiliar impasse. One which calls for a dialectical synthesis.
On one hand we have the needs of our clients. On the other hand we have clinical practice and resource considerations in a dramatically altered world. For many organisations, providers, and clients, video-based therapy offers a pragmatic way forward. At the same time, as is always the case with dialectics, it depends. For myriad reasons, video-based therapy won’t suit all clients, in all settings, all of the time. Nonetheless, that same old advice from your DBT trainers about getting started with DBT holds for video-based DBT. Yes, get a good read of the terrain, and then set off without wasting time, figure out the directions as you go, build the airplane as you fly.
Much has been published and broadcast in the past few weeks on delivering individual therapy sessions by video, none of which needs repeating here (the British Psychological Society has put together a guide on effective therapy by video, including links to various other resources). The bottom-line is that evidence-based psychological therapies can be delivered effectively and safely by video following a decade of research (Anderson et al., 2019; Carlbring et al., 2018; Gros et al., 2013).
Yet, as a multi-modal therapy, delivering DBT by video presents some additional considerations. As DBT teams, we need to provide group-based skills training by video, not to mention therapist consultation team meetings. There might be a temptation to just drop the group skills training mode for now and stick with individual sessions. To this I say, don’t even think about it! We have robust evidence that DBT skills training groups and DBT skills use make a positive impact on clinical outcomes for clients in DBT (Barnicot et al., 2016; Linehan et al., 2015; Neacsiu et al., 2010). Group skills is essential in DBT, period. Yet, video group is daunting for many of us.
The good news is that all of this is very solvable. Many have been here before us, using video for groups and classes across healthcare, education, and commerce. And, indeed, let’s not forget there are already a number of pioneering DBT-informed programmes that have been offered solely online. The experiences and learning from those ahead of our curve in using video can provide us with direction and help us avoid predictable pitfalls. I’d like to share some of these practice guidelines with you in this series.
So, in the spirit of dialectics, I’d like to invite you to proceed with flexibility and a willingness to turn-on-a-dime when needed to roll with the inevitable setbacks. And keep an eye on the prize, which is sustaining your DBT programme through difficult times. Our clients need us to.
But before diving into the details, there’s one clarification that might be useful to make. Here we are considering migrating in-person DBT programmes and skills group to video due to the life-saving restrictions imposed by social distancing and the likelihood that it will be many months before groups of individuals can gather together again in person. Presumably therapy-by-video was not part of expectations for DBT, for you as a provider or your clients. This unanticipated situation is probably coming with a thunderous jolt. Transitioning to video-based therapy needs some new therapeutic contracting. Informed-consent also needs attention depending on the requirements of your jurisdiction and your employer.
Let me assure you that you’re not alone if this whole prospect feels uncomfortable and unwelcome. At the same time we are all in this together, as a wider community of therapists and a wider community of clients.
Yet, as clinicians, we need to lead our clients on this new adventure and sow seeds of confidence that this will work. Harvard-based psychologist Amy Cuddy’s well-known adage of “fake it until you become it” definitely applies! The migration to video is more likely to succeed if you throw yourself fully into participating in video work, like you’ve being doing it everyday of your working lives. Don’t make mealy mouthed apologies to clients about being a novice, creating uncertainty and doubt. Group members will look to you for their cues. Confident trainers breed confident skills groups, even if this means that like some of the best actors or actresses in the business, you will sometimes shake with doubt backstage before you go on. You need to act as if you know what you are doing, even if you don’t!
Read here for Part 2, in which we will begin to address specific behaviours for successful video work.
Dr Jim Lyng is a senior counselling psychologist for statutory community mental health services in Dublin. Read Jim’s full biography here on the British Isles DBT Training site.
Anderson, G., Carlbring, P., & Rozental, A. (2019). Response and remission rates in internet-based cognitive behaviour therapy: An individual patient data meta-analysis. Frontiers of Psychiaty, 10, Article 749.
Barnicot, K., Gonzalez, R., McCabe, R., & Priebe, S. (2016). Skills use and common treatment processes in dialectical behaviour therapy for borderline personality disorder. Journal of Behaviour Therapy and Experimental Psychiatry, 52, 147-156.
Carlbring, P., Anderson, G., Cuijpers, P., Riper, H., & Hermcan-Lagerlof, E. (2018). Internet-based vs face-to-face cognitive behaviour therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cognitive Behaviour Therapy, 47, 1-18.
Dunkley, C. (In press). Regulating emotion the DBT way: A therapist’s guide to opposite-action.
Gros, D.F., Moreland, L.A., Greene, C.J., Acheron, R., Strachan, M., Egede, L.E., Turk, P.W., Myrick, H., Freud,B.C. (2013). Delivery of evidence-based psychotherapy via video telehealth. Journal of Psychopathology and Behavioural Assessment, 35, 506-521.
Haase, R.F., & DiMattia, D.J. (1970). Proxemic behaviour: Counsellor, administrator, and client preferenc for seating arrangement in a counselling analogue. Journal of Counselling Psychology, 17, 233-236.
Linehan, M.M., Korslund, K.E., Harned, M.E., Gallop, R.J., Lungu, A., Neacsiu, A.D., McDavid, J., Comtois, K.A., & Murray-Gregory, A.M. (2015). Dialectical behaviour therapy for high suicide risk in individuals with borderline personality disorder: A randomised controlled trial and component analysis. Journal of the American Medical Association Psychiatry, 72, 475-482.
Neacsiu, A.D.,Rizvi, S.L., & Linehan, M.M. (2010). Dialectical behaviour therapy skills use as a mediator of treatment for borderline personality disorder. Behaviour Research and Therapy, 48, 832-839.
Porges, S. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. New York, NY: W.W. Norton & Son.