Question 1

What software/methods would you use for sharing diary cards and chain analysis virtually? Is there any recent research noting pros/cons for delivering DBT in a virtual setting?

Emily Cooney · Accepted Answer

Hi there! I'm not aware of any published findings on the pros and cons of delivering DBT remotely as yet, although you can bet that a number of people are working busily away attempting to clarify exactly those issues.  The question of outcomes associated with in-person vs online DBT was a major topic in a recent online discussion among DBT clinical researchers, and several are collaborating to pool data to try and elucidate this.  There are data to show remote delivery of prolonged exposure garners similar outcomes to those obtained from in-person delivery of this treatment, which is heartening.  The one system I've personally used for sharing materials virtually with clients is the MyChart function of the electronic medical record Epic.  We've created fillable pdf versions of our in-house diary card and chain analysis forms, although I think just having folks take a picture of their completed chain and uploading it to whichever platform you use likely works just as well.  I've seen people express a lot of positive comments about psychsurveys on the dbt listserv, and haven't used this myself - and in the interests of disclosure should note that the developer of this platform is the husband of a former student of mine, so I'm not exactly an independent party.  Forgive me if I'm saying water's wet (or 'being captain obvious' as a gen Z client told me recently), but I think the main things about which every process you use is ensuring it's easily  accessible to both you and the client, and HIPAA-compliant.  Good luck!

Question 2

Is there any published research for virtual-based DBT?

Gwen Abney-Cunningham · Accepted Answer

Hi! I am not aware of any published findings on the pros and cons of delivering DBT  virtual based.  I am aware that there are people who are gathering information regarding this.   While data is being gathered, it is really important to be mindful continually assess  with the individual (s)  who are receiving comprehensive DBT  via  virtual based  , that it is meeting both  their short term and long term needs.

Emily Cooney · Answer

Hi there! I'm not aware of any published findings on the pros and cons of delivering DBT remotely as yet, although you can bet that a number of people are working busily away attempting to clarify exactly those issues.  The question of outcomes associated with in-person vs online DBT was a major topic in a recent online discussion among DBT clinical researchers, and several are collaborating to pool data to try and elucidate this.  There are data to show remote delivery of prolonged exposure garners similar outcomes to those obtained from in-person delivery of this treatment, which is heartening.  Keep an eye out - data are on their way!

Question 3

I have a client that believes her wise mind is an "oracle" and feels like it is not really her, even though she knows it has to be her. The way she describes the experience I wonder if it is a dissociative state? How can I help her access wise mind?

Emily Cooney · Accepted Answer

Hmm, what an interesting question!  You know, hand on heart, I can actually relate to this client.  Sometimes, asking my wise mind about something seems like consulting an oracle too.  Without knowing more about her description of the experience, it's difficult for me to comment on the question of whether this is a dissociative state.  I think I would be inclined more to assess whether the answers she's receiving when she consults her own intuition and wisdom are helpful and effective for her.  Does accessing her wise mind lead to adaptive behavior that helps her attain her goals?  If so, I would be less concerned (at least in the short-term) about her experience of connection to her wise mind.  The fact that she knows that it has to be her may be enough for now, particularly if her sense of herself and life is often discontinuous and fragmented - in fact if that's true, it's a major win that she can access her oracle!  If she herself is distressed by the nature of her experience, I would assess her concerns further, and have a very open mind about whether the solutions were acceptance, or change-based - or a dialectical combination of skills.  It's likely that with practice of wise mind, especially with trialing the use of different exercises to access it, and steady consistent practice of the other mindfulness skills, that her sense of connection to her own wisdom will grow and change.

Question 4

Given the challenges involved in providing group-based skills training via video and therapist consultation team meetings, is it okay focus on individual sessions and drop the skills group during the COVID-19 shutdown?

Emily Cooney · Accepted Answer

I can understand why you would be tempted to! And, somebody's got to provide DBT skills training sessions during these times when arguably our clients need skills and community the most.  Also, if we're not meeting weekly as a consult team, we're not doing DBT, so somehow or another, if we're not meeting together in-person as a team, we have to figure out how to do things online.  I've actually been pleasantly surprised at how smooth the transition to remote groups has been once we've sorted out the infrastructure and orientation at the outset.  Certainly the post-millenial (i.e our gen Z) clients have adapted most quickly to this new way of doing things, but their older compadres are by and large not far behind.  I've tried to respond to this new way of doing things with flexibility, warmth and humor and have found that clients have been amazingly forgiving of the odd tech snafu, and very responsive to the behavioral experiment approach of 'let's see how this goes'.  The key pieces for both group and consult team meetings have been a secure and HIPAA compliant platform, and means of sharing materials such as diary cards, homework sheets, and skills manuals between group leaders and members, and for consult team, a HIPAA-compliant online storage facility for keeping the agenda, agreements, roster for roles, and related stuff (e.g. virtual bell for teams that don't like the broken sound that emanates when a real bell echoes across the zoomisphere), and ensuring this is easily accessible to all consult members, along with clear guidelines about when and how to update it prior to the meeting.  We've found having each member open it up in a secure form of Box is better than the note-take sharing their screen during the meeting, because we'd rather see each others faces consistently in a meeting.  Anyway, I'm digressing!  In short, or the tldr (see, my millenials are teaching me): I say get the infrastructure right, and give it a shot.  You'll be in hot demand, you'll be providing more DBT modes to people who need them, and you may find it's a lot more rewarding than you anticipate.  Good luck!

Question 5

Due to factors such as fatigue and engagement, would it be advisable to reduce the length of the skills training group if it's being conducted via video?

Emily Cooney · Accepted Answer

Hi there! So far, we haven't done this, and have found that people are reasonably active and engaged, and that attendance has  actually improved since starting remote session delivery, because people don't have to navigate transportation issues - once they've figured out how to connect with us.  I should note that we have a 15 minute break after we've done the homework review hour, then resume for skills instruction for the following hour.  We've modified some of the mindfulness activities we're doing to make them more zoom-friendly (e.g. asking people to name the next person to go in observations about a practice, or to take part in a participate exercise involving turn-taking, as there's no virtual equivalent to circle - just a brady bunch grid that varies between viewers).  If people look like they might need up-regulating, we have chosen activities that involve more movement when we can (e.g. self-soothing with stretching rather than listening to music, dancing rather than singing for participate exercises, etc).  As stated on another thread about muting vs unmuting, we've had to use creative ways of leveraging zoom functions such as chat, and polls to foster engagement and drama into proceedings, and have found that group members have been quite responsive - we also try to inject a lot of humor and drama into proceedings with this (e.g. let's all use this poll to rate our before SUDs, and now...how about after??? Oh my goodness, these ratings are plummeting! Looks like paced breathing is really effective).  We've also played around with having 'audience' members turn their cameras off and select 'hide view for non-video participants' during IE role plays, so that group members get a nice clean view of the 2-3 participants in a role play and cracked jokes about our stars as we go - and having the brady bunch grid view for more socially anxious role-play participants.   Good luck!

Question 6

How should we manage clients wanting to or secretly recording sessions?

Emily Cooney · Accepted Answer

I've been worried about this in groups since the advent of smart phones! Frankly, my experience is that group members are very thoughtful and protective of each other's privacy, although I have found that young people can be a little mindless about uploading pictures to social media - and are very responsive to corrective feedback about this.  However, I'm not so certain they're concerned about group leaders' privacy! There was one incident in which I was the shapee/'animal' in the shaping game with a group of adolescents and parents and they were getting me to do all sorts of embarrassing things.  In a moment that I had a balloon between my knees I had visions of seeing myself on youtube, and had urges to halt the game right then.

Ok: if clients want to record/have been recording their individual sessions, I would be singing hallelujah, because listening to one's session recordings between therapy sessions is one of the main strategies in the DBT manual for fostering generalization.  However, they may not record group sessions, and including this statement in the guidelines for group members when reviewing privacy might be an important aspect of orientation in this era.  As part of orientation for all members on joining the group, they should be providing agreement to protect the group's confidentiality by ensuring they're wearing earphones, and meeting in a space where other people can't see their screen or hear what's being said, and not recording group content.  It's also a risk that precedes COVID; while covertly recording the session is arguably easier to do when you're attending remotely, it can also happen for in-person sessions - group members could easily press record on their devices before switching to airplane mode and laying them on the group table.  As a therapist, I think we must attend to the infrastructure as best as possible e.g. ensuring that recording the session isn't enabled for group members, and also acknowledge the limitations of our reach.  This means ensuring that members are informed of the limitations to confidentiality that are an inherent part of online group skills training, given that we have less control of the individual environments of each group member.

Question 7

Do you have your group members mute or unmute when not speaking? The benefits of everyone muting are clear e.g., noise reduction but this may encourage passivity and interfere with spontaneity etc.

Gwen Abney-Cunningham · Accepted Answer

Great Question! I think it depends on your group and the platform you are using.   We have experienced that  if everyone has there mics on we have gotten horrible feedback.   
When we began skills classes  virtually in group formats,  we facilitated  conversations with participants discussing pros  and cons of mute/non mute  and having camera on/not on.   Participants landed , mostly , on muting and having camera on.   They identified having camera on and seeing each other was a way to feel connected.   For a few, they identified not wanting to have the camera  on feeling self -conscious.  As the group problem solved, they landed on it it was "good exposure."  They recognized, if they had an appointment with  their physician, professor, employer  during the COVID crisis, it likely would be virtual.  It is a great example of making lemonade out of lemons!!!

Emily Cooney · Answer

Hi there - great question! I think in this current COVID19 era, we're all focusing on dialectical flexibility and mindfulness...which means trying things out, and seeing how they go.  In general, I've asked people to stay on mute, unless they're speaking.  When we were pivoting to telehealth groups, we had a very careful orientation to using zoom, and included things like a mindfulness exercise involving fully participating in using the space bar to quickly momentarily unmute and say things without planning them first.  Lately, I've been experimenting with using the chat function sometimes for people to offer descriptions of their experience (e.g. observing and describing their emotional experience after we've all watched an emotionally evocative clip together following an orientation to the model of emotions, or feedback about their experience of paced breathing/PMR etc), which has offered up some surprisingly rich interactions.  Generally I have people pause and review all of these for a few minutes afterward, and then invite different members to comment on their experience, or the co-leader might review and moderate these - I've heard that sometimes chat can get tricky with adolescents and think it's important not to enable private chats between members.  We've also reinforced people using their body language to express something - I don't like the zoom emoticons much, but I like it when people do a thumbs up for the camera, clap in front of the lens, or put their fist on their chest/heart to convey support or approval for another group member's statement, and am sure to model these behaviors myself and comment positively about it when others do them.  These expressions do seem to leaven the atmosphere and inject more spontaneity in interactions.   There have also been times when I've asked everyone to unmute, at points we're having a group discussion, and just chat, and then I have everyone mute afterwards, when I'm going back to teaching the next swathe of content.  I think if the group is especially quiet, they're wearing earphones, and they are in a quiet environment, you could trial having the mute buttons off for a full session, and see how it goes, then dial it back if this approach tanks.  Group members in our program tend not to be living in quiet environments though; walls are thin and they have multiple people living with them.  Andrea Gold has compiled a list of suggestions for mindfulness practices that are telehealth-friendly on the DBT listserv.  I hope these ideas help with facilitating spontaneous and active communication on line!

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