This document discusses considerations for a DBT graduate group program. Key points include: things that improve with DBT like behaviors and emotions but still need work like applying skills; current lack of aftercare programs; areas a graduate group could focus on like emotional experiencing, strengthening skills, building a life worth living, and transitioning out of treatment; proposed structure and rules for a graduate group; and providing worksheets and homework online.

1. DBT Graduate Group
BEYOND SKILLS TRAINING

2. Things that are better after DBT
 Behaviors typically under  Emotions under better
control control
 Self-harming is decreased  Mood labiality decreased
 Visits to the hospital  Better understanding of
decreased emotions
 Impulsive behaviors and  Less likely to act in
anger outbursts decreased emotion mind
 Suicide attempts decrease,
but suicidal ideation
typically remains the same

3. Things that still need work
 Clients can stop unwanted  Ability to apply skills to real-
emotions, but still reluctant to life situations
feel emotions and allow them  Know skills, but not sure what
to return to baseline naturally to use when
 Unresolved trauma
 Clients have learned to NOT  While clients may “act” better,
think about the trauma they do not “feel” better
 Creating and fulfilling
personal accomplishments  Inability to obtain happiness
 10 year longitudinal study in life
shows that while service use
decreased, BPD patients are  When clients say, “I can’t be
never regain functional happy,” they may be right.
abilities  Biofeedback studies indicate
 More likely to stay on disability that BPD struggle to feel
 Less likely to return to positive emotions
workforce, school or other
“productive” activities

4. Current aftercare programs
 Very little available
 Linehan addresses issue, stating that the current manual only
addresses Stage I
 She recommends that for Stage II treatment, providers use
Exposure Therapy as developed by Edna Foa (manual
available)
 However, may not be appropriate for all clients
 Only addresses PTSD/trauma
 Does not Stage III or Stage IV

5. Current aftercare programs
 DBT ACES
 (Accepting challenges of exiting the system)
 Used in community mental health setting
 Focused primarily on discontinuing treatment and reliance on
mh center
 Secondary focus on employment/vocational rehabilitation
 Little to no emotional regulation component
 Only aftercare program to date with specific evidence
supporting effectiveness

6. Pilot studies
 Multiple pilot studies about continuing DBT
 Self-esteem focus
 Assertiveness training focus
 “Booster” sessions helpful at decreasing relapse
 Adolescent graduate group model
 Small scale study, little evidence behind it
For information on actual articles, please see Amy for the references

7. Creating a DBT graduate group
 Areas of focus:
 Emotional experiencing
 Getting beyond stopping emotions, allowing self to feel
 Unresolved trauma (better done in individual or trauma specific
treatment)
 Generalizing and strengthening skills
 Knowing what skill to use, when to use it and being able to apply it to
day to day problems
 Building a life worth living
 Developing and following through on goals that will make life better
 Transitioning out of treatment
 Providing a slow transition out of treatment
 Helping to find supports outside the mh center

8. Emotional Experiencing
 Allowing clients to feel emotions rather than block
them
 Using the Ways to Describe Emotions from the
Emotion Regulation Module
 Talking through each one, allowing for examples
 Using guided imagery during the sessions to
experience emotions through to the end

9. Generalize and Strengthen Skills
 Members can teach skills each week
 Group chain analyses in which one member
describes a situation and other members offer
suggestions for skills use
 Cope ahead plans
 Preparing for emotions ahead of time and having skills ready
to use

10. Building a life worth living
 Using skills to determine what they would like to
work on
 Setting a goal
 Breaking goals into manageable steps
 Tracking goals
 Following through on goals
 Rewarding self for completing tasks
 Being able to problem solve barriers

11. Transitioning out of therapy
 Developing support systems outside therapist
 Using Interpersonal Effectiveness Skills to create new
friendships or rekindle old ones
 Developing activities outside attending therapy
 How else could they use the time? What would they rather be
doing?
 Using Pleasant Events Schedule to find more to do
 Beginning to trust self and own decisions
 Don’t need a therapist to work through every problem
 Developing self-sufficiency in solving day to day dilemmas

12. New rules for graduate group
 Attendance is flexible – come when you want
 Can discontinue the group at any time
 Can return at any time for “booster” sessions
 Diary cards are optional, but each person must keep
a goal tracking sheet
 Each person must commit to working on a goal
 If no goal, cannot be in group
 May need several weeks to determine goal
 Focus of group remains skills based
 Not a therapy group, any problems presented are to help
decide which skills to use

13. New rules for graduate group
 Cannot be actively engaging in self-harming
behaviors
 Cannot actively be using drugs/alcohol
 Cannot have been in the hospital in the last three
months
 Has to have successfully completed all four modules
of the DBT skills group

14. New rules for graduate group
 Facilitators take less active role
 Facilitators are there as consultants
 Facilitators may help keep group on track, but group members
are responsible for decisions about group activities
 Clients are encouraged to “act as the expert”
 On the skills and mindfulness
 On their own needs, wants, desires and hopes

15. Structure of Group
 Mindfulness Activity
 Led by group member
 Skills Review
 Skill taught by group member
 Client choice
 Work on goals/goal worksheets
 One member presents chain analysis and receives feedback
 Emotional experiencing
 Discussing aspects of different emotions
 Group wrap up
 Weekly commitments (What do you agree to work on?)
 Closing mindfulness activity
 Led by group member

16. Worksheets and Homework
 All worksheets and directions for creating and
developing goals can be found on the client website
at:
 http://www.jcmh.org/DBT/Graduate/graduate.cfm