Somewhere towards the end of your training in DBT there was probably a point where you felt overwhelmed at the prospect of what lay ahead. It just all seemed so big. There was the task of learning this new therapy, as well as playing your part in implementing or sustaining DBT in your service setting, not to mention getting your mind around this strange new idea of a dialectical worldview. But if you think back, at this point in time there is also a good chance that you were getting a clear message from your DBT trainers which sounded a little like the Nike slogan: Just Do It. Overthinking, too much planning, excessive caution – these understandable responses, your trainers told you, are enemies of getting DBT up and running. Certainly, they agreed that there are important strategic and clinical questions that need to be resolved before any DBT programme kicks off. Yet your trainers likely also pointed out that many a seasoned and successful DBT therapist, including themselves, have their war-stories of learning DBT on the hoof, book in hand, client or group in the room, taking one step at a time, using observation, feedback and measurable behavioural change as instructors. If you reconstruct your journey of becoming a DBT therapist, there probably wasn’t a specific eureka moment where when you realised you had just ‘got it’. At the same time, I suspect that if you hadn’t just jumped into the pool you’d probably still be sitting there on the edge, thinking and worrying and coming up with excuses, wondering what water felt like, instead of doing laps like it was your birthright.
Just Do It.
And so it is with the transition from bricks-and-mortar, in-person DBT to video-based DBT. Take the plunge. For many of us video therapy may not be a forum or medium we would ever have chosen for our clients or service. Equally, many of our clients didn’t sign-up to have us video-call into their homes, Star Trek-style, with all of the new clinical dilemmas and practical challenges this poses. Yet here in the middle of this Covid-19 fuelled emergency, which increasingly looks like it will define much of at least the next calendar year, where staying apart from one another is literally a life-saver, in the same way that DBT is a life-saver, we find ourselves at an unfamiliar impasse, one which calls for a dialectical synthesis. On one hand we have the needs of our clients. On the other hand we have clinical practice and resource considerations in a dramatically altered world. For many organisations, providers, and clients, video-based therapy offers a pragmatic way forward. At the same time, as is always the case with dialectics, it depends. For myriad reasons, video-based therapy won’t suit all clients, in all settings, all of the time. Nonetheless, that same old advice from your DBT trainers about getting started with DBT holds for video-based DBT. Yes, get a good read of the terrain, and the set off without wasting time, figure out the directions as you go, build the airplane as you fly.
Much has been published and broadcast in the past few weeks on delivering individual therapy sessions by video, none of which needs repeating here (the British Psychological Society has put together a guide on effective therapy by video, including links to various other resources: https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Effective%20therapy%20via%20video%20-%20top%20tips.pdf). The bottom-line is that evidence-based psychological therapies can be delivered effectively and safely by video following a decade of research (Anderson et al., 2019; Carlbring et al., 2018; Gros et al., 2013). Yet, as a multi-modal therapy, delivering DBT by video presents some additional considerations. As DBT teams we need to provide group-based skills training by video, not to mention therapist consultation team meetings. There might be a temptation to just drop the group skills training mode for now and stick with individual sessions. To this I say, don’t even think about it! We have robust evidence that DBT skills training groups and DBT skills use make a positive impact on clinical outcomes for clients in DBT (Barnicot et al., 2016; Linehan et al., 2015; Neacsiu et al., 2010). Group skills is essential in DBT, period. Yet, video group is daunting for many of us.
The good news is that all of this is very solvable. Many have been here before us, using video for groups and classes across healthcare, education, and commerce. And indeed let’s not forget there are already a number of pioneering DBT-informed programmes that have been offered solely online. The experiences and learning from those ahead of our curve in using video can provide us with direction and help us avoid predictable pitfalls. I’d like to share some of these practice guidelines with you below.
So, in the spirit of dialectics, I’d like to invite you to proceed with flexibility and a willingness to turn-on-a-dime when needed to roll with the inevitable setbacks. And keep an eye on the prize, which is sustaining your DBT programme through difficult times. Our clients need us to.
But before diving into the details, there’s one clarification that might be useful to make. Here we are considering migrating in-person DBT programmes and skills group to video due to the life-saving restrictions imposed by social distancing and the likelihood that it will be many months before groups of individuals can gather together again in person. Presumably therapy-by-video was not part of expectations for DBT, for you as a provider or your clients. This unanticipated situation is probably coming with a thunderous jolt. Transitioning to video-based therapy needs some new therapeutic contracting. Informed-consent also needs attention depending on the requirements of your jurisdiction and your employer.
Let me assure you that you’re not alone if this whole prospect feels uncomfortable and unwelcome. At the same time we are all in this together, as a wider community of therapists and a wider community of clients. Yet, as clinicians, we need to lead our clients on this new adventure and sow seeds of confidence that this will work. Harvard-based psychologist Amy Cuddy’s well-known adage of “fake it until you become it” definitely applies! (www.ted.com/talks/amy_cuddy_your_body_language_may_shape_who_you_are/up-next?language=en) The migration to video is more likely to succeed if you throw yourself fully into participating in video work, like you’ve being doing it everyday of your working lives. Don’t make mealy mouthed apologies to clients about being a novice, creating uncertainly and doubt. Group members will look to you for their cues. Confident trainers breed confident skills groups, even if this means that like some of the best actors or actresses in the business, you will sometimes shake with doubt backstage before you go on. You need to act as if you know what you are doing, even if you don’t!
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.
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 morely liket 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.
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.
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 – deliberating 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).
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.
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 undoubtably 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.
About the Author: Jim Lyng is an accredited DBT therapist and trainer. He recently spent a number of years working for a global tech company which served as his trial-by-fire in the art and science of video-conferencing. In the past few weeks, Jim has helped child and adult mental health services migrate onto video, including full DBT programmes.
Special thanks to Dylan Moore and his crack-team of DBT therapists at St. Patrick’s University Hospital in Dublin, Ireland for being first-in-line to migrate fully to video-based DBT and pioneering and providing feedback on many of these ideas.
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