This feature by Ronda Oswalt Reitz, PhD is Part 1 of 2 in a series about communication tips to make a DBT consultation team effective in a virtual world. In this first part, Ronda begins by looking at communication and coping ahead.
You buy a new pair of pants that look and feel…amazing. Striding out into the world you try not to seem too aware of how great you look. Unfortunately, there is a suspicious looking stain on the seat of those pants that you didn’t notice. How long do you have to move through the day before someone tells you? Who in your life is most likely to tell you? Getting that feedback will depend upon having people in your life who are observant, care about you, and are confident enough in the relationship and themselves to be direct. There is an intimacy in giving unpleasant feedback that makes it somewhat rare in life. This means that we sometimes persist in behaviors we would do well to give up, if someone would only mention it.
In the world of therapy, a consultation team is the place where we receive honest feedback. Team is the best friend who says, “Those pants are a PERFECT fit. And they have a stain that you may not have noticed on the back.” And you’re grateful. Dialectically, you may also be a bit annoyed with the messenger, but if you’re skilled in reinforcing this rare phenomenon, you thank them anyway and can then move forward to solve the problem. Is your consultation team offering meaningful clinical feedback for all of its members? If not, then an important piece of direct feedback will be to say, “I want to bring up a team interfering behavior on my part.”
The team is the meeting place of humility and precision in DBT. Ideally it forms a safety net of wise mind that supports each therapist. A base of compassion among all members and direct, behavioral communication are required in order to strengthen and generalize treatment strategies to a high level of precision.
All members of the team commit to bringing mindful presence, openness, and confidence to this process. When members struggle in giving or receiving feedback it is most often because vulnerability has become overwhelming and these qualities are no longer available to them. The Oxford definition of vulnerability is “…being exposed to the possibility of being attacked or harmed either physically or emotionally.” High levels of vulnerability can arise from any number of sources, inside or outside of the team, and can result in self-protective shielding that is counter to the goals of a team (and treatment).
Like most things in life, confidence and vulnerability fluctuate depending upon a variety of both internal and external factors. If you have been on a DBT team for any length of time, you have no doubt experienced hearing something that concerns you and have felt both pressure and reluctance to be the person who provides feedback. If the issue is related to accuracy in the delivery of the treatment, it is an important part of our role as team members to bring it out in discussion. The goal is not to eliminate feelings of vulnerability so that it’s comfortable to give feedback, but rather to be mindful of those feelings and to move forward into skillful communication anyway.
Agreeing to join a DBT team means being committed to going “where angels fear to tread.” This means giving feedback even when it is possible that the other person will react defensively. Awareness of vulnerability—both our own and that of others on the team—allows us to respond to the situation with behavioral feedback before vulnerability becomes overwhelming and our skills are compromised. In any given moment, what determines how long you wait to say something or whether you speak up at all? What vulnerability factors contribute to your silence? What factors help you in saying even difficult things?
Naming Barriers to Communication
Dedicating some time to working on communication issues outside of the weekly team meeting can be a good investment for teams who notice an absence or uneven delivery of clinical feedback. If your team is struggling to communicate directly and with behavioral language, the first step is to identify any unspoken barriers—the elephants in the room. Consider starting with a missing links analysis. Reflecting inward, each person thinks of a specific incident in which they did not speak up when it would have contributed to the health of the team.
The following prompts may be helpful, allowing time for each person to reflect and write:
- Am I committed to increasing direct and behavioral communication in team?
- Did I know that direct communication was needed in a particular moment to solve the problem?
- What happened when I knew it would be effective to speak, but I remained silent? Note any observed emotions, actions, thoughts, environmental factors, and sensations that occurred.
- What barriers to speaking up were present? Consider the barriers to being skillful—specifically handouts 2 and 2A in the Interpersonal Effectiveness module and handouts 4 and 4A in the Emotion Regulation module.
Once this work is completed, each team member can share their own team interfering behavior in turn. The task of the individual member in this process is to share their own experience, not to speak to the original issue (a potential elephant). This part of the exercise is intended to focus fully on the responsibility of the team member. They should describe to the team all other elements of the missing links analysis, including how the team will know when they struggle to communicate directly, and how the team can help them speak to the issue the next time it comes up.
When thinking about our own vulnerability factors that lead to either overly intense or restricted responses on team, broaden awareness to patterns expressed in other settings (e.g., freezing in the face of expressed anger), current life events (e.g., pandemic), acuity of case load, etc. Just as we do with clients, we want to reduce vulnerability to extreme reactions in team, including the tendency to shut down. Raising awareness of our own cues when this is happening and describing them to the team helps us to notice them earlier and to head off a more intense reaction when that wouldn’t be helpful.
In addition, simply describing physical and emotional cues can be helpful to the team in recognizing transactions that may not contribute to effective functioning of the team. For instance, if an emotionally expressive team member begins to raise their voice, another member might describe their own physical and emotional responses. “I’m noticing that my heart rate increased when your voice level rose above conversation level. I felt tension in my body, and I’m not taking in any more information.” This allows the other team member to recognize the impact of their own verbal and non-verbal behavior and to make adjustments if needed, and for the team to provide support to both members.
Coping Ahead
The next step is for the provider to identify interventions likely to result in their increased use of direct and behavioral feedback in their situation. The range of solutions available to therapists are exactly the same as those for clients: skills, exposure with response prevention, cognitive modification, or contingency management. This requires looking carefully at the missing links analysis, considering the function(s) of the behavior, and selecting one or two interventions most likely to result in effective behavior change. For many therapists, the function of not providing feedback is to avoid an extended and uncomfortable conversation and/or conflict. Here are some examples of solutions a therapist might implement, given dysfunctional links at various points in the missing links analysis:
| Link S | Solution |
| Vulnerability factor; Extreme fatigue due to lack of sleep, resulting in expressed irritability (Skills Deficits) | Sleep hygiene protocol; Mindfulness of irritability with response prevention (opposite action); Turn the mind and listen with curiosity |
| Fear response to anger; Physiological arousal, freeze response | Exposure to expressed anger; Mindfulness of fear, speak in a calm tone to the other person in the presence of fear |
| Thoughts – “They won’t listen anyway” or “They aren’t sophisticated enough to understand” | Non-judgmental stance reframe (CBT); DEARMAN GIVE FAST (which is also opposite action |
| Fear of not being able to find the words to say what they are thinking; Fear of feeling ashamed after speaking up | Plan a DEARMAN, GIVE, FAST; Have team reinforce therapist for speaking in a way that is meaningful for them |
Once the therapist has identified one or two strategies they think will be effective in changing their behavior, discussing the plan publicly with the team anchors commitment. The team can participate in shaping and reinforcing the therapist’s behavior by highlighting examples of the problem and/or reinforcing use of the solution each time it is observed in team. In fact, the solution can be formalized into a “treatment plan” of sorts. It might be useful for the observer to track each person’s target and goal or for members to do so themselves and provide a brief check-in at the end of team.
It isn’t a simple thing to translate well-worn concepts and judgments into accurate and factual language. Taking time in team to identify any conceptual, interpretive, and/or judgmental words and practicing changing them into behavior language is something that is helpful to all teams. Adding this to a teaching agenda will reduce opportunities for misunderstanding and increase curiosity.
Under usual circumstances it is a challenge to use behavioral language and to be direct in communication. Under conditions of high or chronic stress, this becomes even more difficult. Read here for part 2, in which we will explore practical ways in which teams can increase effectiveness while dealing with the many layers of stress brought on by the pandemic.
Ronda Oswalt Reitz, PhD is the Coordinator for Dialectical Behavior Therapy (DBT) services for the Missouri Department of Mental Health. Dr. Reitz specializes in large-scale implementation of DBT and has developed comprehensive DBT programming in community mental health systems, inpatient hospitals, and in juvenile and adult forensic settings. Read her full bio here.
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