This feature by Allison K. Ruork, Ph.D. and Shireen L. Rizvi, Ph.D., ABPP of Rutgers University is Part 1 of 2 in a series about DBT skills generalization. In this first part, Allison and Shireen begin 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.
Comprehensive Dialectical Behavior Therapy (DBT) is thought to help people via five functions: enhancing client motivation, enhancing therapist motivation and capabilities, environmental intervention, skill acquisition and skill generalization. In this post, we focus on skills generalization, that is, the translation of skills learned in treatment to the client’s natural, “real life” environment. While this post is most applicable to DBT therapists, clients who are looking for additional methods to help strengthen their skills use at home may also find it helpful.
Since we are typically only in treatment with clients three hours a week, making a plan for skills generalization is critical. There are near infinite metaphors to use for discussing this need! One example is to imagine you were training for a cross country marathon but only ran three hours a week and only on sidewalks and roads. How would that practice translate to 26 miles of trails and hard-packed dirt? Not well! Other favorites include being told how to ride a bicycle and then trying for the first time in heavy traffic. Playing a piece of music in front of a huge audience, after only practicing it for 3 hours in a quiet space, and so on.
We rely on metaphors like these to convey the extraordinary importance (and difficulty) of skills generalization, but what can we do as DBT therapists to actually facilitate it?
The answer most often is two things: homework and phone coaching.
Homework assigned in individual and group serves dual functions of strengthening skill acquisition, as well as generalization. But perhaps the mode of DBT most frequently associated with skill generalization is phone coaching.
Phone calls in DBT typically fall into four categories: crisis management, skills coaching, relationship repair, and good news. Each of these types of calls either explicitly demand skills practice (e.g., skills coaching) or implicitly lead to skills practice (e.g., calling to discuss a ruptured relationship often requires opposite action and at least some distress tolerance skills). Non-DBT therapists are often anxious about phone coaching “Clients have your personal cell and can call you ANYTIME?!” Ironically, DBT therapists are often frustrated because they struggle to get clients to use it.
Since phone coaching tends to be conceptualized as the primary means of skills generalization, it is worth unpacking some of the pros and cons.
The pros are real-time, in the moment opportunities for behaviorally specific feedback and clarification of how to implement a skill. The ability to do this as situations unfold in the client’s environment can be extraordinarily powerful. It also communicates to the therapist that the client is thinking about skills and trying to use them! In our experience, this can offset burnout and declines in therapist motivation. The very preliminary data on the use of phone coaching appears to support this. Data suggest that phone coaching is associated with greater client improvements, as well as increased client and therapist satisfaction (Edwards et al., 2021; Chalker et al., 2015).
This is not to say there are not drawbacks to providing phone coaching. High numbers of crisis calls (though, importantly, not skills generalization calls) may increase therapist burnout (Ruork et al., under review). There are often a number of barriers to providing coaching as well, including provider barriers (e.g., availability, limits, avoidance), institutional barriers such as settings that prohibit after-hours coaching (e.g., many VAs and college counseling centers), and client barriers often in the form of worry about burdensomeness and avoidance. In addition, many clients prefer texting and do not respond to calls well, yet there are additional challenges to texting, including institutional barriers, as well as how text content may be interpreted.
Given the potential benefits and the challenges related to phone coaching, it is not something to give up on AND it does not need to (and likely shouldn’t!) be the only way we approach skills generalization.
Read here for part 2 of this piece, in which Allison and Shireen go into greater detail on alternatives for skills generalization, which include many opportunities that stem from recent technological advances.
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.
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).