Using Skills in the Natural Environment: Strategies for Enhancing Skills Generalization (Part 2)

This feature by Allison K. Ruork, Ph.D. and Shireen L. Rizvi, Ph.D., ABPP of Rutgers University is Part 2 of 2 in a series about DBT skills generalization. In the first part, Allison and Shireen began by discussing making a plan with clients on how to use DBT skills in a real world environment and how homework and phone coaching can facilitate the process. Here in part two, they discuss alternatives to phone coaching and technological advances that have created more opportunities for skills generalization.

When we left off in part 1, we noted the benefits and drawbacks of phone coaching to support clients in using DBT skills in a real world environment.

So, what are the alternatives? Recent technological advances have made more opportunities for skills generalization than Linehan could have imagined when writing her manual! Additional means of skills generalization include listening to session recordings, use of crisis plans, mobile apps, web-video adjuncts, DBT games, and DBT podcasts (see Figure 1). While not all of these strategies will work for everybody, they are worth exploring in order to meet the function of generalization.

Making and listening to recordings of sessions is an original DBT strategy (Linehan, 1993) and an excellent one. Gone are the dark days when we had to remember to purchase blank audio cassettes and therapists had to make sure they had tape recorders! Clients can record on their smart phones. For those doing teletherapy, Zoom and other platforms can save audio-only files (unless the therapist is also recording). Not only does this give clients the opportunity to think about and practice skills on an additional day, recordings of in-session skills practice can then be used outside of session. Listening to session can be helpful for a variety of reasons. Clients may not remember session well if they’re dysregulated. It’s also almost like getting another hour of therapy during the week. It is important to work with clients to help protect privacy. Setting phone passwords, deleting recordings after listening, using headphones etc. may all help keep session recordings confidential. For those submitting recordings for certification, this is also a treatment adherence upgrade! So, it benefits you too!

Crisis plans are another well known, but potentially under-utilized, option. A crisis plan may help clients who are struggling to remember skills outside of session because they are early in treatment, dysregulated etc. Assigning practicing the crisis plan as homework early in treatment, assessing how the practice went, and making needed revisions (repeat as needed) may help clients practice most needed skills and identify gaps in skills generalization. Having a hard copy version with the skills spelled out (like this one) and combining this with a crisis survival kit can also increase the likelihood that skills are practiced outside of individual and skills training sessions.

Mobile apps are an emerging and potentially useful way of increasing skills generalization. Many of the available DBT skills apps use a decision-tree like process that helps clients both learn and apply skills in their environment, as well as strengthen their ability to identify what kind of skill they need. The empirical support for these apps is in its infancy (indeed many of the apps with empirical support are not even in the marketplace) and more research on them is needed, yet many people enjoy these apps and find them useful. Clinicians should review apps to make sure DBT content is presented with fidelity, as well as assess the financial cost to clients when determining whether to suggest an app for generalization purposes. In addition to skills-focused apps, there are myriad diary card apps, and other potentially useful apps that are not explicitly DBT, like the virtual hope box which can function like a virtual crisis survival kit.

Another useful option is DBT skills videos on YouTube. Before calling (or under the same conditions when we would want them to call if they can’t), clients can view a skills video or even a whole playlist. The videos walk through the use of the skill, much in the same way a therapist might if they called for coaching. There are a number of videos on YouTube that have been created by experts in DBT, including videos of Marsha explaining skills (like this one) and these short animations (all around 5 minutes) created by our DBT Clinic at Rutgers University. There are, of course, others, but if you go searching make sure to assess for video quality and fidelity to the DBT model before recommending to clients.

A very unique approach to skills generalization is the use of games. “The Game of Real Life” and “WTF Happened?” gamify applying DBT skills. Both were developed by Jesse Finkelstein in collaboration with our DBT clinic at Rutgers University. In “The Game of Real Life” players must use (play) DBT skills cards to navigate their way through life events and obstacles. “WTF happened?” is less a game as it is a game-looking tool for conducting a chain analysis, but it may encourage clients who struggling with chains (either in or out of session). Both games may be particularly helpful for families and couples going through DBT as they can play and learn together in their own homes. Those who are interested can find details about both games here.

Finally, podcasts are an increasingly popular means of delivering psychological content and can be a great option for a deep dive into individual skills. “To Hell and Back” by Dr. Charles Swenson and “Therapists in the Wild,” created by Dr. Molly St. Denis and Dr. Liza Pincus, are a couple of great options, though there are certainly more (as with videos, assess for quality prior to suggesting podcasts to clients). In addition to discussing how to use skills, Therapists in the Wild hosts provide feedback to each other (and occasionally guests) on how skills can be applied in different situations. Listening to podcasts may help prompt clients to think about skills in their own environment and help them practice when needed (e.g., listening to a previous episode when they need help practicing a skill).

Videos, podcasts, and games, like those listed above, provide information about skills and lead to imaginal rehearsal and use of skills in the client’s own environment. Other means of increasing skills generalization may also function in this way (e.g., listening to recorded sessions). However, whether it’s watching a video to practice a skill, using a mobile app or any of the methods mentioned above, practice outside of therapy is likely crucial, and is in need of ongoing assessment. If the method isn’t serving the function, that is a problem that needs to be solved! Moreover, these strategies could potentially be stacked in order to increase gains in skill use. Dialectically, we never want to give up on phone coaching AND we may need to be flexible in order to meet the desired function.

Figure 1: Examples of multimedia strategies for skills generalization

Interested to learn more about phone coaching? Read here for this blog on Phone Coaching in DBT.  

Shireen L. Rizvi, PhD, ABPP, is a Professor of Clinical Psychology, Director of the Dialectical Behavior Therapy Clinic (DBT-RU), and Clinical Associate Professor of Psychiatry at Rutgers University. Read her full bio here.

Allison K. Ruork, PhD, is a postdoctoral associate at GSAPP. Allison received her M.A. and Ph.D. from the University of Nevada, Reno and completed her internship at Duke University Medical School. Read her full bio here.

References:

Chalker, S. A., Carmel, A., Atkins, D. C., Landes, S. J., Kerbrat, A. H., & Comtois, K. A. (2015). Examining challenging behaviors of clients with borderline personality disorder. Behaviour Research and Therapy, 75, 11-19.

Edwards, E. R., Kober, H., Rinne, G. R., Griffin, S. A., Axelrod, S., & Cooney, E. B. (2021). Skills‐homework completion and phone coaching as predictors of therapeutic change and outcomes in completers of a DBT intensive outpatient programme. Psychology and Psychotherapy: Theory, Research and Practice.

Rizvi, S. L., Dimeff, L. A., Skutch, J., Carroll, D., & Linehan, M. M. (2011). A pilot study of the DBT coach: an interactive mobile phone application for individuals with borderline personality disorder and substance use disorder. Behavior Therapy, 42(4), 589-600.

Rizvi, S. L., Hughes, C. D., & Thomas, M. C. (2016). The DBT Coach mobile application as an adjunct to treatment for suicidal and self-injuring individuals with borderline personality disorder: A preliminary evaluation and challenges to client utilization. Psychological services, 13(4), 380.

Ruork, A. K., Yin, Q. & Fruzzetti, A. E., (2021). Between-session contact and burnout in therapists using dialectical behavior therapy [Manuscript Under Review].

Schroeder, J., Wilks, C., Rowan, K., Toledo, A., Paradiso, A., Czerwinski, M., … & Linehan, M. M. (2018, April). Pocket skills: A conversational mobile web app to support dialectical behavioral therapy. In Proceedings of the 2018 CHI Conference on Human Factors in Computing Systems (pp. 1-15).

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