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The Move You Never Thought You’d Be Making: How to Get a DBT Skills Training Group Online in the Time of Corona (Part 2)

How to Get a DBT Skills Training Group Online in the Time of Corona part 2

This feature by Dr. Jim Lyng is Part 2 of 3 in a series about bringing a DBT Skills training group online during the time of the COVID-19 pandemic. In part 1, we examined the need for this pivot. Here in part 2, we are introducing the first three behaviours for successful video work.


In part 1 of this series, we noted that evidence-based psychological therapies can be delivered effectively and safely by video and that DBT skills training groups and DBT skills use make a positive impact on clinical outcomes for clients in DBT. At the same time, video group can be daunting for many of us. With that in mind, there are five behaviours for successful video work, and we will take a look at the first three today.

Introducing PETS – five behaviours for successful video work

Like any social environment, video work needs particular behaviours to succeed.  Unfortunately many of us don’t have much practice with cultivating these behaviours because outside of clinical supervision by video most of us haven’t worked at all using this medium (and no, those FaceTime calls to pals or family where you’ve held a shaky phone right in front of your faces and self-consciously yelled down the phone don’t count as preparation for video therapy!) 

The overall goal is to break through the ‘virtual-wall’, creating an experience which resembles an in-person encounter. As a committed DBT therapist, I couldn’t resist the opportunity to create an acronym for effective video  behaviours – PETS.  PETS consists of two ‘p’s for picture and posture, ‘e’ for eye-contact, ‘t’ for technology, and ‘s’ sound. Let’s take a brief tour across all five.   

Picture

In terms of picture, everyone who joins the video group session will be visible to everyone else.  As a result, getting picture right becomes a community effort – it’s not just for the therapist, everyone needs to get on board.

Encourage your clients – and yourself – to use a full-monitor (i.e. desktop, laptop, or tablet) wherever possible.  The screen size on even larger smart phones is still too small for optimal video therapy, all the more so with joining a group.  By contrast, a full-sized monitor will fill central vision and feels more like a live, in-person conversation. 

With a group meeting it improves the experience for everyone to use a gallery view format where you can simultaneously see everyone, or many, at once.  This builds group rapport and helps dilute the risk of things becoming overly didactic. 

Ensure everyone makes an effort to avoid shaky cameras.  Shakiness is inescapable when holding a device in your hand, so no hand-held devices, no matter what, for the sake of everyones’ sanity.  It’s possible to be driven to absolute distraction when one video participant starts mimicking an earthquake in the far corner of the screen with a shaky camera.  Get everyone to find a spot for the camera, set it down, and keep it there, no moving between rooms, for the entire group session.  Where there is no alternative to using a smart phone, make sure clients set their phones down on a piece of solid furniture. 

And regardless of the type of camera device, everyone needs to position the camera at a good angle.  I’m still amazed at the types of bizarre camera angles people use for video calls – how do they even manage those sideways, sort-of-upside-down, moody shots from carpet level?  Hitchcock would be proud, but don’t be a Hitchcock – this is a DBT skills group!  Along the same vein, watch-out for placing laptops on laps – legs shake also, so devices need a solid, non-breathing, non-living base.  

Watch out for under-the-chin views of your nostrils – it’s not a good look for starters, and more importantly it  interferes with forming a rapport – you will appear austere, aloof, and judgemental.  Aim for a face view which is at a level with the camera.  And sticking with camera view, you should be visible from the waist up. Decades of research tells us that about half of all communication happens via gesture and posture, much of which takes place through arms, hands especially, as well as the upper body.  As a trainer you need to use everything at your disposal so that you can to get your message across – exactly what you would do in an in-person skills group.  Where possible, coach your clients to do the same and set themselves up on camera so that you can also see them from the waist up.  A wider view gives you valuable data on how they’re responding to the skills training – are they still with you or did you lose them back at the last junction or did they even leave the starting gates with you?  Body-language seldom lies.  

One more nugget on picture – everyone, therapists and clients alike, needs to think about lighting.  It might sound like a purely cosmetic consideration, but it actually falls into a critical aspect of a successful video meeting. 

If lighting comes from behind you’ll look like a silhouette and an unintended dead-ringer for the villain in a slasher movie in which case almost everything in the preceding discussion with be moot.  Light needs to come from the side or head-on so that you are clearly visible.  

And on the subject of being visible – make it a requirement that everyone turns on their cameras.  It might not be comfortable for some group members who do not want to see themselves on a screen, but being able to see all participants is a reasonable expectation for everyone joining a video meeting.  I’ve sat through many a video meeting with some joiners coming in with their cameras turned off, and it’s frankly unnerving.  Having cameras on is also an indirect way of shaping up the right attitude towards the group.  People will be more likely to show up groomed, mentally and physically prepared, not calling in from under their duvet.  In my view, this is one of those things to explicitly agree in advance of the first video session – joining without a camera, unless there is an unexpected technical reason, should not be an option.

Posture

Correct posture serves two functions – it helps sustain everyone’s attention and helps keep everyone emotionally regulated.  

Since a DBT skills training group is typically between two and two and a half hours posture really matters.  Sitting in a cramped or awkward posture for a sustained period of time causes physical pain, the number one enemy of attention.  Think about how a large chunk of the first session of a meditation training programme usually focuses on showing you how to sit – it’s a convention that shows sensitive awareness to the importance, and complexity, of sitting well. 

DBT skills training groups can be demanding at the best of times.  In moving online, we lose the soothing balm of in-person peers, not to mention the inevitable hassles and imperfections of technology.  The result here is that the video skills group can come with additional strain without the natural release valves of the spontaneity, rapport and fun of the in-person skills group.  It can all become a caldron for emotional dysregulation among a group who are already emotionally vulnerable.  This all needs some careful correction. 

I strongly recommend putting in 1:1 coaching time with group members to figure out where they should sit and how they should sit.  While your clients might savour the idea of joining the meeting and curling into a favourite corner of the sofa, this will inhibit participation through either discomfort or sleepiness.  Ensure all group members are sitting in an open, upright posture which facilitates alertness and is likely to reduce pain due to sitting for an extended period of time. 

Encourage a bit of physical movement during the skills group, and if someone looks bored ask them to move, to stand-up, do a loop around the room, stretch, or whatever works in the service of participation.  In terms of staying regulated, DBT already offers many ways in which we can deliberately use our bodies to shape our emotional responses in a bottom-up manner, especially through opposite-action (Dunkley, in press).  Of additional relevance is the role of an open posture and deep breathing in down-regulating neurophysiological states of threat and arousal through activation of the ventral vagal system (Porges, 2011).  And don’t miss the opportunity to coach some radical acceptance with willing hands and a half-smile where needed – the video group itself could become an excellent laboratory for skills practice!  

The co-leader has an especially vital role to play here, just as they do in an in-person DBT skills group.  As always, the co-leader is responsible for monitoring group members’ in-session responses and intervening as needed, solving barriers to learning that show up, behavioural or technical.  Private chat via the video conferencing can be an especially helpful tool for coleaders to reach out to group members during a video group session where the co-leader can provide feedback and coaching as needed without interrupting the group.  This allows the leader to keep their foot on the pedal in the direction of new learning and skills practice.   

Eye-Contact

Regarding eye-contact, the key behaviour to avoid is eye-balling your clients, unflinching, like the type of character you would prefer not to meet from an old David Cronenberg movie. 

I’m willing to wager that in an in-person skills group, you’d move your gaze around the room, carefully avoiding making a fixed or intense stare.  Try to mimic this natural ‘roving gaze’ on video, including allowing yourself to look away from the screen, as you might naturally do when thinking as you speak. 

Again, keep in mind the over-riding goal, to simulate a natural experience.  Sometimes this involves a little bit of theatrics on your part – deliberately acting what you would normally do, even though it doesn’t feel right. Since theatricality is a common skillset of many good DBT skills trainers, the chances are high that you already have this in your repertoire of behaviours – remember to draw on it!  If you review a recording of your delivery of a skills group you’ll quickly see how helpful a deliberate use of gaze and eye-contact becomes – it will make you more relatable and human. 

Also, as a welcome byproduct, keep eye-contact loose and natural will also help you feel less exhausted. 

Trust me, staring for two hours plus is very tiring, and maybe you’ve already discovered this with early video efforts – video based work is somehow much more tiring that in-person work and you will need to make accommodations for this. 

In terms of promoting natural eye-contact, I’ve found orientating my chair at a forty-five degree angle in relation to my screen helps greatly – just as I would when setting up my room for an individual therapy session. This simple adjustment helps me widen my gaze and offsets the tendency to stare into the screen – and is consistent with fifty year old research which found that clients prefer when chairs in therapy have been arranged at an angle (Haase & DiMattia, 1970).  

Read here for Part 3, where we will address the last two 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.

References
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.