This feature by Dr. Jim Lyng is Part 3 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. Previously in part 2, we introduced the first three behaviours for successful video work. Here in part 3, we conclude with the final two behaviours Jim recommends.
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. Part 2 of this series examined the first three, and today we focus on the final two.
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 our last two behaviours.
When it comes to technology, prepare to do some radical acceptance – your tech will fail you sometimes. Fortunately, since DBT is a recursive therapy where therapists learn and apply the same skills and strategies as their clients to themselves, I’m guessing you’ve already made progress in mastering radical acceptance and coping ahead!
When tech failures happen, accept it, don’t fight it, the facts are the facts – then have a contingency plan. This usually means being ready to switch seamlessly to telephone (mainstream video conference platforms usually include telephone numbers for joining). Ensure your clients are orientated in advance on how to ‘old-school’ telephone into the meeting and instruct all clients to have their phones to hand for the entire duration of the video-based DBT skills group in case you need to telephone or text them for any reasons whatsoever (which would usually be carried out by the co-leader).
Another indispensable way to trouble-shoot for technology is to deliver individual tutorials on video calls to all group members in advance of the first video skills session. In these individual tutorials and coaching sessions you, or a member of your DBT team, can make sure sure microphones and cameras are working and help clients become familiar with whatever video conferencing software you have chosen to use, including privacy settings. This is also a good opportunity to focus on the other elements of PETS, such as posture and camera view.
On the subject of privacy, make sure all group members are in control of how their names are displayed on the screen – for reasons of confidentiality it is important that neither full names of clients or personal contact details are visible to other members of the group. How to achieve this will depend on the platform you are using.
Also, one other critical point on privacy, make sure recording functions are disabled on your video platform during the skills group – most platforms store video content to the cloud which would be against most healthcare agency policies. A tidy fifteen minutes of targeted coaching can prevent a cacophony of chaos during the first video skills group, an experience which can turn everyone off video before you started. Remember, as with all things in life, first impressions last! Insofar as possible you want to give the video group a fighting chance with a fairly smooth first experience on video. And again, when things do go wrong, as they will, tech support becomes a fascinating new part of the job-description of the co-leader!
When it comes to sound, I’m a big advocate of using headphones for video calls. They serve several functions which can enhance people’s overall experience.
Firstly, they assist with privacy, as no one in the client’s environment – or yours – can accidentally overhear anything that is coming in over the video meeting. In addition, headphones usually improve sound quality, and allow people in the meeting to speak quietly, and naturally, into their microphones without have to shout at screens, an off putting characteristic of video calls I have observed over the years (and again this helps with privacy, as the client is less likely to be overheard outside of where they are joining the meeting).
As with everything however, it depends. Factors such as the quality of the built in microphones on the client’s device, client preferences, whether a client has headphones etc. will all be relevant. Nevertheless, options around headphones are worth exploring in advance.
Also, in terms of sound, do not be shy to use the mute function for the meeting. Ideally, at any point in time only the person speaking should be unmuted on a group video call – otherwise there can be any amount of background noise, from heavy breathing, to the clicking of keyboards (likely to drive people to a state of rage!), to children, to pets, to traffic, to feedback. It takes bit of practice, but over time group members will become used to this practice of muting/unmuting and it will start to flow like normal turn-taking in an in-person meeting. It also creates a beautiful opportunity to mindfully pause before you speak or respond! And when the meeting gets noisy, as the leaders, mute and reorientate.
A last comment on sound is that leaders will need to get used to training into silence. Initially, this can be a bizarre and disorientating experience . You may be able to see some of the group members depending on your platform settings, with hopefully some encouraging visual feedback, but possibly not – and you will be receiving no auditory feedback. Imagine delivering a talk to a room of people in dead silence – it can be the stuff of nightmares – but this is exactly what you will need to learn to do at a video skills class. This brings us back around to theatrics again – even in the absence of feedback, you need to push ahead with training – using natural cadences, pauses, inflection points, even laughing at your own jokes. It’s strange. Be brave.
Mindset Matters There’s nothing left for it, but to get started. Make sure you do some rounds of rapid feedback with group members after the first few video group sessions which will undoubtedly help you improve your game. And be kind to yourselves as you get started – this is no time for unrelenting standards. This is one of those many instances in life where done is much better than perfect.
And lastly, don’t lose sight of the simple fact that as a leader and therapist, your mindset matters. If you hold the belief that this is a poor substitute for the ‘real thing’, I have no doubt that you’ll lower your standards and expectations, and your clients will match you. This is a grand experiment – aim for the stars, you might very well get there.
If you want to read more about DBT Skills in the COVID-19 Pandemic, check out this excerpt of a discussion between Tony DuBose, PsyD, Chief Training Executive at Behavioral Tech, and Esequias Caetano, a psychologist in Patos de Minas, Brazil.
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.