A 6-SESSION BASIC DBT SKILLS PSYCHOEDUCATIONAL GROUPIN A MIDDLE SCHOOL SETTING

Wake Forest UniversityTawnya Fabian, Mark Fields, and Natasha Gillyard

GROUP RATIONALE

In an extensive review of international statistical literature regarding non-suicidal self-

injury and deliberate self-harm, Muehlenkamp, Claes, Havertape, and Plener (2012) found that

the lifetime prevalence of these behaviors in adolescents was between 12.5% and 23.6% and

between 12.2% and 31.4% respectively. The large discrepancy between the first and second

figure in each category is due to assessment method; the lower figures are from studies using

single item “yes” or “no” responses, and the higher figures are from studies using multiple item

checklist surveys. Regardless of which statistic one wishes to acknowledge, self-harming

behavior obviously has a significant prevalence in adolescent populations. Given that self-

harming behavior is alarmingly common among adolescents across age and cultural boundaries,

any interventions that may impact this problem should be considered. The school environment is

integral to the lives of most adolescents, and a brief group intervention may be a viable way of

efficiently delivering information to adolescents. “Group counseling in schools is a central

means of supporting student growth and development.” (Perusse, Goodnough, & Lee, 2009, p.

230).

Cognitive skills and meditative techniques taught in dialectical behavior therapy (DBT)

groups have been shown to mitigate self-injurious behaviors, and we propose that an introduction

to some of these skills may act as a first step in prevention of such behaviors for early

adolescents (Neacsiu, Rizvi, & Linehan, 2010; Seligman & Reichenberg, 2012; Seligman &

Reichenberg, 2010). DBT has had success in reducing the occurrence of self-harm and suicidal

behavior, the latter being perhaps the most dire outcome for any mental health diagnosis

(Neacsiu, Rizvi, & Linehan, 2010; Seligman & Reichenberg, 2012). Because patient

development of DBT skills has shown effectiveness in mediating both suicidal and non-suicidal

self-harm, and longer term DBT treatment has been successful with adolescents, a skills

development group may benefit adolescents exhibiting self-harming thoughts and behaviors

(Neacsiu, Rizvi, & Linehan, 2010; Perepletchikova, Axelrod, Kaufman, Rounsaville, Douglas‐

Palumberi & Miller, 2011; Seligman & Reichenberg, 2010).

DBT attempts to reverse maladaptive patterns by concurrently validating a client’s

emotional and affective responses, and replacing them with a new acceptable pattern of thought

and behavior (Hampton, 1997; Linehan, 1993). Early adolescents experiencing emotional

distress in this time of changing social, cognitive, and biological stimuli may need validation

(Berk, 2010). Crespi noted (as cited in Perusse, Goodnough, & Lee, 2009), “as students share

and process together, school psychologists use their counseling skills to promote mutual trust and

help members develop a sense of inclusion within the group” (p. 227). The small group we

propose will validate the individual’s experience by showing them that they are not alone in

having these thoughts, feelings, and behaviors, and will begin the process of replacing their

responses by teaching them some basic coping strategies. DBT skills development has

demonstrated promise specifically in reducing self-harming behaviors, as well as suicide

attempts, depression, and anger control (Neacsiu, Rizvi, & Linehan, 2010).

Although more research is needed, some preliminary research suggests that brief, DBT

skills-based interventions show promise. In a study by Ward-Ciesielski (2013), a single one-hour

session that was dedicated to teaching adults with suicidal ideation five basic DBT skills (rooted

in mindfulness, emotional regulation, and distress tolerance) resulted in a majority of individuals

reporting that the intervention had been helpful. A significant increase in the use of skills taught

at a one-month follow-up was also reported. In a six-week trial of DBT group therapy for

children, skills learned may be effective and implementable, based on self-reporting of children

and parents (Perepletchikova, Axelrod, Kaufman, Rounsaville, Douglas‐Palumberi & Miller,

2011). Thus, even a brief psychoeducational skills development group may have potential in

positively benefiting a population of early adolescents engaged in, or with a history of, self-

harming behaviors.

Our goal is to plant the seed for development of new coping strategies, and the rejection

of self-destructive ones, for the adolescents in our group. In a large cross-sectional study,

McMahon, Corcoran, McAuliffe, Keeley, Perry, and Arensman (2013) found a strong correlation

between self-harming thoughts and actions and adolescents who had emotion-oriented coping

styles versus problem-oriented coping styles. Self-harming was found to be even more strongly

correlated with emotion-oriented coping styles when an individual had mental health issues such

as depression, anxiety, and/or low self-esteem. Cognitive approaches such as DBT and CBT

have been shown to be effective in treating depression and anxiety. DBT skills focus specifically

on emotional regulation and distress tolerance, while cognitive responses to distress are by

definition problem-oriented versus emotion-oriented (Neacsiu, Rizvi, & Linehan, 2010;

Seligman & Reichenberg, 2010). Therefore, development of basic DBT skills may be useful in

introducing new coping strategies to adolescents with unsuccessful emotion-oriented coping

styles. This may also contribute to helping adolescents manage the effects of mental health

issues that are correlated with self-injurious behaviors, such as depression and anxiety.

Based on the above information, we hypothesize that a brief psychoeducational group

focusing on development of DBT skills may validate the experiences of self-harming

adolescents, while teaching them new strategies for dealing with their emotions and behaviors in

a non-destructive way. We intend to develop a preliminary DBT psychosocial group designed to

impart some basic self-regulatory skills and to provide social support to early adolescents

engaged in current or previous self-harming behaviors.

GROUP OBJECTIVES

Upon completion of the six sessions, students should:

Be able to use the skills they learn in situations outside of the group

Gain a greater sense of universality from being in the group with other kids who self-harm.

Learn alternatives to self-harm for use in situations of emotional distress.

Understand the meaning of self-esteem and its importance on how group members value themselves.

Gain an understanding of the role of advertising and commercials on self-esteem.

Be more confident in their ability to deal with emotions and stressful situations.

Become familiar with how to refocus if they are getting distracted.

Experience how it feels to be part of a group and to trust peers and a person in an authoritative role.

PARENT/GUARDIAN INFORMED CONSENT

To the parents/guardian of ____________________________________________________

A six-week counseling group will be offered to students who have exhibited self-harming behaviors, and your child has been identified as a student who might benefit from participating in this group. This counseling group will be limited to six to eight students, and will focus on giving your child alternatives to self-harming tendencies.

The counseling group will meet once a week for six weeks. The sessions will be scheduled for 50 minutes, and will take place during academic hours.

Information shared by your child is confidential unless your child or another person may be in physical danger.

Kindly return the signed form (below) immediately to ensure that your child can participate in the counseling group. Please contact me with any questions or concerns. I can be reached at the phone number or email address provided below.

I look forward to hearing from you. Thank you.[Name of School Counselor][School Phone Number][Counselor’s School Email Address]--------------------------------------------------------------------------------------------------------------------

Student’s Name: _______________________________________________________________

o Please include my child in the counseling group

o I do not want my child to participate in the counseling group

_______________________________________________________ ________________________Parent/ Guardian Name (please print) Phone

_______________________________________________________ _________________________Parent/Guardian Signature Date

_______________________________________________________ ________________________Parent/ Guardian Name (please print) Phone

_______________________________________________________ _________________________Parent/Guardian Signature Date

_______________________________________________________ _________________________Counselor Signature Date

STUDENT CONSENT FORM

I _______________________________________________________, agree to participate in the counseling group for students with self-harm issues.

I understand this is a group that will meet for once a week for six weeks, starting on October 14, 2013 and ending on November 18, 2013.

I understand that my attendance in the counseling group is very important.

I understand that anything we discuss in the group will be confidential UNLESS: I know of someone who is in danger I am causing harm to myself or to someone else

__________________________________ _________________________Student Signature Date

__________________________________ _________________________Counselor Signature Date

SIX SESSION GROUP PLAN

Session One: Introduction

Session Two: Mindfulness

Session Three: Distress Tolerance

Session Four: Emotion Regulation

Session Five: Self-Esteem

Session Six: Review and Wrap-Up

DBT SKILLS GROUP

Session One

Time50 minutes

Materials White board and dry-erase markers.

Objectives Introduce the group members to each other. Explain the rules and parameters of the group. Help the group members feel comfortable with each other and the school counselor. Instill a sense of trust about the confidentiality of sharing experiences with each other.

Ice Breaker Introduce self, and one activity you enjoy doing, and your favorite book, movie or tv

show. Once each group member has answered, ask each person to choose an activity, book, movie, or tv show that someone else mentioned that he or she would also enjoy.

Welcome to your group experience! Discuss that the purpose of this group is to discuss about how each of the group members

have had negative feelings about themselves – They have been angry, sad, or frustrated by other people, and have probably been angry and upset with themselves.

Let the group members know that in this group, they will be able to openly share Be sensitive while discussing that everyone in the group has had the urge to, or has, hurt themselves experiences in a circle of trust.

Inform the students that they will learn new strategies to help them cope with their lives, and their emotions, that are not self-destructive.

Discuss with the group members that after the six-week group counseling sessions, they will know more about themselves, learn about and from each other, and gain a new understanding that they are not alone - that others feel what they feel, and they can choose a different way to cope.

Rules of Group Counseling!

Affirm that this group is FOR the students, and some very important, non-negotiable rules are in place:

1. Everything discussed in this group is confidential. What is said or heard in this room cannot be shared with anyone outside of the group.

2. (The counselor) will not speak with anyone including the group members’ parents, teachers, or the principal, about information that is shared, unless someone’s life is in immediate danger, or if something that indicates another person is in immediate danger. This is a safe environment.

3. Stress the importance of attendance. The productivity of the group requires weekly attendance by all members. If someone is absent, the growth of the group suffers. Ask for the group members’ commitment to regularly attend the sessions, and to let (the counselor) know if they will be unable to meet so that (the counselor) can inform the other group members.

However, some rules can be established by the group members, which are not set in stone.

o Use the dry-erase board to write down suggestions from group members about the rules that are important to them.

o The dry-erase board will be in place for each session, and can be modified by changing, adding, or subtracting rules as the group becomes established.

o This will give the group members a feeling of empowerment, and subtly encourages involvement. Further, shows the group members that the counselor is there for them, and not the other way around.

o Keeping the dry-erase board visible at each session is a developmentally appropriate way to remind them of THEIR rules. Also, because the group members have collaborated on making the list of rules, the group members might feel comfortable indicating an infraction to one of their peers who breaks a rule.

Examples of what the group members might identify as rules for the group:1. Nobody interrupts anyone else while they are talking.2. Be sensitive, no laughing3. Do not disparage someone for what they share in group

Activity: This activity will show us that we each bring something different to the group and we

each need each other. You can each bring one thing on a desert island and we will see how we can bring each of our objects together so that we can survive.

Lost on a deserted island

Following a shipwreck, everyone has been stranded on a deserted island. Each person is allowed to bring one object to the island, ideally something that represents him or her, or something that they enjoy.

Each person is asked to describe what object they would bring and why (doesn’t have to be realistic: guitar, dog, food). Encourage creativity.

After everyone has introduced their object and why they have chosen the object, ask everyone to work together to improve their chances of survival by combining the various objects that they introduced. If necessary, add more objects, but be sure to use all objects that participants mentioned.(www.icebreakers.ws/team-building/lost-on-a-deserted-island.html)

Coping Skill: Conscious breathing exercise:

o We are going to see who can count the most breaths. o Have the group members close their eyes and sit in a comfortable position. Ask them

to breathe normally, in through the nose and out through the mouth. Let them take a few breaths.

o Now start counting in your head. Time this exercise for about 3 minutes. o Ask the group members if it was hard to keep counting. Ask them how high they

were able to count? Also ask if the noticed what caused them to be distracted while they were counting.

If it seems to be working for the group and if enough time is left in session, then proceed to part two.

o Now we will do the same thing without counting. Ask the group members to simply focus on their breath this time. After about 5 more minutes close session (it is hard for most beginners to meditate for an extended period).

Close Session: Process activity. Invite questions or comments on the session. Invite the group to

practice the breathing exercise at home, explaining that the group will return to that exercise through the sessions, and that they should try to use the breathing when they want to be calm.

Thank everyone for coming. Remind the group members about next week’s session, and dismiss.

DBT SKILLS GROUP

Session Two

Time50 minutes

Materials Ball or Mason Jars for all participants and leaders. Assorted glitters and colored sands portioned out for each member Water Liquid dish soap Small gong or bell Digital Clock

Objectives Each student will learn a mindfulness technique that they can use outside of class.

Ice Breaker What do you do to relax? Sharing of ideas. This ice breaker is purposefully meant to

keep the group members calm in anticipation of teaching the objective of the session.

Mindfulness Questions: Start off with a series of questions:

1. “Do you ever find it hard to concentrate in class or at home? 2. Do you sometimes find you can’t stop thinking about something, like something bad

that happened, or something you are worried about? 3. Do you sometimes realize you have no idea what your teacher or the person you are

talking to is saying, or do you forget what you were just about to do? 4. Do you sometimes feel like these thoughts are taking over, like you can’t stop them

even when you want to?”

Mindfulness Explained: Explain that most people are distracted all the time.

o Sometimes we are thinking about what we want to say even before a friend stops talking.

o Sometimes we wander right past what we are looking for in the store because we are lost in thought and forgot what you are there for.

Explain that mindfulness is a way to stop being distracted. Not only can it stop us from being distracted, but it can make some of those uncomfortable thoughts go away.

Learning mindfulness can help us learn to see, hear, and smell what is around us, and stop worrying about things and enjoy the moment you are living in.

o Ask if the group members have ever noticed that the moment they began speaking a sentence, the thought is already gone, and new thoughts and feelings emerge while they are speaking the sentence.

o Tell them that this is exciting because it means we can be new people any time we want to. We change every moment, so if there is something in your life we want to change, we can change it just by living in the now.

Activity One: Have everyone sit with his or her eyes closed.

o Explain that a timer on the digital clock will start when the gong is rung (or bell).o Everyone is to sit with their eyes closed until they think it has been one minute.

Do not count the time and try not to think about anything. o The group members do not get up or say anything when the minute is over, but

just notice what the time on the clock says. The leader will prompt everyone when the last person opens his or her eyes.

Ask the following questions:o Raise your hand if it had been less than a minute when you opened your eyes.

How much less? o Think about how you approach things in your life. Do any of you rush through

things? Do you often show up early? o Do you feel like you don’t have enough time? o Do you get stressed out by time, or do you feel impatient?

o Raise your hand if it had been more than a minute. How much? o Do you think this affects you? Are you often late? o Do you feel distracted often? Have you ever been called absent-minded?

Explain that many times we are unaware of what is happening around us. We do not know how long a minute is. We are in a hurry to get through things or we are distracted.

o Discuss that this is even worse when bad things happen. When feelings are hurt, or we are angry or sad, most of us either dwell on it or try to push through life without thinking about it. Either way, the emotion is not being dealt with it and we can’t let go.

o Discuss that when we cannot get past these things, we might be tempted to hurt ourselves just to make the negative emotions go away. This next exercise is a way for you to use mindfulness to let go of negative thoughts and feelings without ignoring them or making them worse.

Activity Two - Mindfulness Jar Exercise: Give everyone in the group a jar filled with the soapy water solution and separate

assorted portions of sand and glitter. o Ask everyone to think of some things that are bothering him or her.

Explain that this can be a person, maybe an ex-boyfriend, someone who is mean

Something that happened, maybe you were embarrassed or you fell off your bike and hurt yourself or your parents punished you, anything that makes him or her upset.

Ask them to think of things that are stressing them out, like homework or a test. Let them know that stress can come from something that is good, too, like hoping that a girl or a boy likes them, or taking a family vacation.

For each of the things that are bothering him or her, have the group member choose a color of glitter or sand. Scoop some up and dump it in the jar. Explain that the person or thing can no longer get to the group member, it is stuck in the jar.

Have the group members keep going, and put as many scoops as he or she needs to get rid of all of the things that are distracting him or her, or making him or her feel bad.

When the group members are done, screw the lid back on. Explain that the jar will be used for a mindfulness exercise.

o Have everyone find his or her own space, and shake up the jar. Watch the glitter float around and slowly descend to the bottom. Ask them not to think about anything, just watch and breathe slowly and deliberately. Keep breathing, taking deep breaths and letting them out slowly until all the glitter has settled to the bottom.

Ask how the activity made the group members feel? More calm? More relaxed? Open discussion.

Activity Three: Explain that small mindfulness activities can do a lot to calm people down when they are

stressed, encouraging people not to let his or her feelings take over. Doing these things can help us think and make decisions without getting upset.

Coping Skill: This last activity, which was introduced at the end of the first session, is just to teach the

group members how to breathe. Tell them this can be done anytime, on the bus, in his or her room, even while he or she is in class. The more we learn to breathe, the more we can use the technique when we get upset or feel like we are getting upset.

Conscious breathing exercise:o We are going to see who can count the most breaths. o Have the group members close their eyes and sit in a comfortable position. Ask them

to breathe normally, in through the nose and out through the mouth. Let them take a few breaths.

o Now start counting in your head. Time this exercise for about 3 minutes. o Ask the group members if it was hard to keep counting. Ask them how high they

were able to count? Also ask if the noticed what caused them to be distracted while they were counting.

If it seems to be working for the group and if enough time is left in session, then proceed to part two.

o Now we will do the same thing without counting. Ask the group members to simply focus on their breath this time. After about 5 more minutes close session (it is hard for most beginners to meditate for an extended period).

Close session: In a very soft and calm voice, thank the group members for coming. Inform them that

their homework is to keep practicing your breathing, and to use your mindfulness jar every night. Ask them to think of all the things that happened during the day and imagine putting them into the jar. Then shake it up and let them settle into nothing.

DBT SKILLS GROUP

Session Three

Time50 minutes

Materials Handouts on STOP and DISTRACT (based on Perepletchikova article) Large roll of easel paper with markers

Objectives The students will become more aware of when they are under duress and be able to

control their immediate reactions to the situation. Learn a few strategies to improve their reactions to stressful situations.

Ice Breaker Fear in a Hat

o Group members write personal fears anonymously on pieces of paper, which are collected. Each person randomly selects and reads someone else’s fear to the group and explains how the person might feel. Fosters interpersonal empathy.(wilderdom.com/games/icebreakers.html)

Set the tone by introducing the topic of fear/worry and that everyone has fears. Distribute index cards and pencils to each person Have them complete a sentence (e.g. I feel scared when…; or I am anxious

when…) as honestly as possible, without being so specific that they can be easily identified

Place index cards in hat; each member will pick an index card from the hat and read the concern aloud, trying to explain what the worry means, describing his/her understanding/reflection of the person’s emotions associated with the worry. (Can phone a friend to provide assistance if having difficulty connecting with the worry.)

Explain that there will be no comments on what the reader said, simply listen and go on to the next reader.

After all cards have been read, discuss what some of the common fears were. Builds trust and unity as people realize that everyone has similar fears

Distress Tolerance:

Begin the session by discussing mindfulness from last week. Did the group try to use their mindfulness skills in the past week? Did they use the mindfulness jar exercise? How did it work? Thoughts?

Present purpose of session: This session will help us learn to tolerate distress. When someone or something makes us upset, we need to learn how to deal with it. Explain that this can be a time when we get hurt (like if we fall down or get a bee sting), or it could be when we get sad or angry. If we freak out or get mad or panic right away, this is when we lose control. Mindfulness will help us with this, but part of it is learning what to do.

Introduce negative coping strategies (avoiding potentially fun situations in case they might cause distress, thinking about past mistakes and pains, drugs/alcohol, hurting self, hurting or getting excessively angry at others, eating too much or not enough, unsafe sexual activity, etc.).

Ask for a show of hands if anyone has used any of these coping strategies before. The counselor raises hand too because we have all used maladaptive coping strategies at some point or another.

Reinforce that everyone does these things sometimes, but that these strategies make us feel worse instead of better. We need to learn better ways to cope. This leads into the activities.

Activity One: Write one of the negative coping strategies at the top of one of the pieces of easel paper.

Invite students to come up with the cons of using this coping strategy (eg. In an attempt to avoid situations that may cause distress, a student may say “do not get to make new friends” or “miss out on the fun”). If needed the group leader can start off with a suggestion or two. Repeat this for several maladaptive strategies.

Activity Two: Introduce STOP as an alternative coping strategy. Give handouts and introduce the

acronym STOP. Stop and do not move. Take a step back. Observe what is going on. Proceed Mindfully. This is a particularly good model for how to react when and event occurs.

Role Play: Have paired group members act out a scripted situation using one example without STOP and one where the student uses STOP.

o Example: One student knocks a lunch tray out of the other student’s hands. In the first scenario, the second student gets very upset and catastrophizes

the event. In the second scenario, the student stops, takes a physical step back, looks

at what has happened, remembers to breathe and calm the mind, and then accepts the first student’s apology, tells a teacher what happened, helps the first student clean up the mess, and gets a new tray. At the end of the second scenario, the student has made a new friend.

o This can also be adapted to situations involving bullies, a bad grade on a test, misunderstanding with a teacher or friend, etc. Students may also be encouraged to create their own role-playing examples of how to use STOP.

Activity Three: Now introduce DISTRACT: Give out handouts and explain the acronym.

o DISTRACT is a way to deal with distress. DISTRACT can be used when an unsettling event has occurred, but may be very helpful when we are thinking about or getting upset about a past event. We can use distract to avoid the destructive coping strategies listed above.

o When we get upset or when something is not going well, we can use one of these strategies: Do something else. Imagine a pleasurable event. Stop thinking about it. Think about something else. Remind yourself of positive experiences. Ask for help. Count your breath. Take a break.

DISTRACT activity: Have the student brainstorm in the group about how to use the different DISTRACT techniques in a stressful situation. Have the group members identify situations in which using DISTRACT might be good? Which technique would be best?

Role play using the ideas students come up with for stressful situations and let individual students come up separately and choose their own DISTRACT techniques.

Close Session: Talk about the activities learned. Ask the group members how the mindfulness

techniques from the week before might help with coping and with using DISTRACT and STOP.

Homework: each student should try to use STOP and/or DISTRACT when getting upset or in a negative situation in the next week. Be prepared to share with group.

If there is time, practice conscious breathing again for the last five minutes.

DBT SKILLS GROUP

Session Four

Time50 minutes

Materials TV/Computer Balloons

Objectives To have students be aware of their emotions, and be better able to deal with them using

techniques that they have already been exposed to in previous session

Ice Breaker Telephone Game: Start with one student whispering a sentence into their neighbor’s ear,

and go all the way around the circle, each student whispering what they have heard without asking for it to be repeated. Do this a few times, discussing whether there is a change in the sentence from what was originally said. Have the students note that this is what happens when rumors, gossip, and miscommunications occur.

Emotion Regulation: Open meeting, and ask if anyone has any questions from session 3. After answering any

questions and briefly discussing session 3 material with the group, proceed to introducing emotions:

Explain to the group that today’s session will focus on Reality Testing and regulating our emotions. To regulate our emotions, we will need our mindfulness and distress tolerance skills.

o For Example: What if my friend Martha passes me in the hall with this “look” on her face and doesn’t say hi to me or even look at me? I cannot think of anything I did to her. What’s her problem? Maybe she is mad at me. Maybe she doesn’t like me. Now I start having thoughts about her, I am angry at her or I am sad because I want her to like me. Maybe both. Now I am getting very emotional.

But then I remember STOP. I need to stop, take a step back, and observe what really happened.

Maybe Martha was upset about something. Maybe she was just spacing out… that happens to me sometimes. Ask the group: How can I proceed mindfully and find out what is really going on? I can talk to her, right? I don’t need to go and accuse her of anything or be mad, I can just go up to her next time I see her as a friend and say “hey, how’s it going?” Then I can ask, “hey, I saw you in the hall earlier and you didn’t look up, what’s up?” If she is really mad at me or does not like me, I will find out, but if I get mad at her or avoid talking to her because I got emotional and came up with these thoughts in my own head, I may really lose a friend.

Explain that this is called reality testing. Before we assume the worst, we need to check and see if what we think is actually real. It is easy to get carried away with thoughts and not realize that they are all in our heads.

So what can we do with these emotions? There is nothing wrong with having them, but if we get too carried away, our thoughts and emotions can lead to actions that cause trouble in our lives. They can make us hurt ourselves or hurt our relationships with others.

Rountable Discussion: Ask the students what might have happened if they did not calm down and test reality?

Encourage the students to discuss different outcomes that might have occurred. Ask the students if they think something like this has ever happened to them? Tell them

that they don’t have to be specific unless they are comfortable sharing details.

Emotion Discussion: Explain that this week’s session will be about emotions. Primary emotions: Emotions that we cannot control, nor would we want to.

o For example: If we learn of a loved one who has died, we feel shocked or sad right away; if a friend surprises us with a gift, or we find out we won a context, we feel happy and excited immediately.

Primary emotions, such as fear of an angry dog, may even keep us alive. Secondary emotions are the emotions that we have to learn to deal with. Secondary

emotions are how we react to primary emotions.

Activity: Tell the group members that people are going to hurt our feelings, even people we love.

Explain that sometimes people are just jerks, and we are fully justified in getting angry at them. Still, we can’t hurt them, then we’ll go to jail.

As a rhetorical question, ask the group members what good does it do to hurt themselves? Ask the group to think of a few people with whom they are currently angry with, or who

have hurt their feelings (a friend or family member); maybe someone who causes a group member to think, “I hate his guts!” Perhaps a person who frustrates a group member is a teacher.

Pass a bag of deflated balloon around and have group members takes as many as they wish, and have them draw the faces of the people with whom they are angry on the balloons.

The group members should really focus on those people and how they have made them feel. POP THAT BALLOON! Did that make you feel a little better?

Take a few minutes and pop as many balloons as you’d like. Get out all those feelings toward these people.”

Processing activity: Open discussion about how students feel. Did this cause any relief?

Video about Conflict Resolution: The Waterboy, http://www.youtube.com/watch?v=_ZpDnXYIFjo Poor example of conflict resolution – open discussion about how Adam Sandler’s

character might have handled the situation differently. Was his anger justified?Video about Conflict Resolution:

In The Mix: Conflict Resolution – Thinking It Through (Excerpt) http://www.youtube.com/watch?v=xDoQIpe5TxA

Good example of how to handle conflict resolution – open discussion about using reality testing when faced with conflict.

Homework: When the group members are at home and notice that a negative emotion is escalating,

introduce the members to the idea of squeezing an ice cube in their fists (rather than turning to a self-harming behavior). After a few moments this will be very uncomfortable, but it will not leave a scar and not do damage to your body.

o If that is not enough, at the same time you can pinch yourself or dig your fingernails in without breaking the skin. These things can distract you and you can still get out these emotions without really hurting yourself.

Ask them to contemplate whether when they hurt themselves, does it hurt the people who have made them angry? Does it make them feel better?

Close Session: Revisit the Conscious breathing exercise:

o We are going to see who can count the most breaths. o Have the group members close their eyes and sit in a comfortable position. Ask them

to breathe normally, in through the nose and out through the mouth. Let them take a few breaths.

o Now start counting in your head. Time this exercise for about 3 minutes. o Ask the group members if it was hard to keep counting. Ask them how high they

were able to count? Also ask if the noticed what caused them to be distracted while they were counting.

If it seems to be working for the group and if enough time is left in session, then proceed to part two.

o Now we will do the same thing without counting. Ask the group members to simply focus on their breath this time. After about 5 more minutes close session (it is hard for most beginners to meditate for an extended period).

DBT SKILLS GROUP

Session Five

Time50 minutes

Materials Drawing sheets, markers Age-appropriate contemporary magazines TV/Computer

Objectives To identify different factors which contribute to anxiety and other negative emotions and

self-perceptions. After the session, the students should understand HALT and understand that media may also have an effect on how they feel about themselves and others.

Ice Breaker Ask the students to write their definition of self-esteem on a drawing sheet of paper. Explain that self-esteem refers to how we understand and value ourselves.

o People with high self-esteem are realistic about their strengths/weaknesses and are able to set goals and work toward them with optimism and humor.

They also feel competent in areas they consider important and do not take other people’s negative impressions of them too seriously (refer to Session 4).

o People with low self-esteem have a hard time honestly evaluating their strengths and weaknesses and often have an unrealistic, overall negative impression of themselves.

They take other people’s opinions of their strength and weaknesses more seriously than they should. Also, they do not feel competent in areas they consider important. People with low self-esteem tend to be pessimistic.

Video about Model Transformation:http://www.youtube.com/watch?v=hibyAJOSW8U

Self-Esteem Activity: Tell students that an important first step in building self-esteem is taking a realistic look

at their strengths and weaknesses, likes and dislikes. This helps them know what goals are realistic to pursue, what aspects of their personality and lifestyle to seek to improve, and how to identify their weaknesses without worrying about how others perceive them. Tell students that self-knowledge helps lay the foundation for high self-esteem.

Then tell students they are going to complete a personal inventory during this session to help them achieve better self-understanding. Tell students to follow the directions, filling in blanks or checking the answers that apply to them. You may copy the inventory for students, read it out loud, or write it on a piece of newsprint and post it in the classroom.

PERSONAL INVENTORYSchool Subjects. I like ______________.. I do not like ________________.. I am good at __________________.. I am not good at _______________.. I am good at this subject, but I do not like it: ____________.. I am not good at this subject, but I like it: _______________.Activities. I like __________________.. I do not like ________________.. I am good at _________________.. I am not good at _________________.. I am good at this activity, but I do not like it: _________.. I am not good at this activity, but I like it: ____________.. I prefer being involved in individual activities _____ or group activities ___. (Check one.)Relationships with Friends and Adults (Check the statements that apply to you.). I am generally well liked: ____________.. I am generally not well liked: ___________.. I have a group of friends: ________.. I prefer having one or two friends: _______.. I am a leader: ___________.. I am a follower: _________.. I prefer people who like the same things I like: ___________.. I prefer people who like different things: _____________.. I have the support of significant adults in my life: __________________.. I have the support of a group of peers: ______________________.Food Preferences. I like to eat ____________.. I do not like to eat __________.. I do ____ do not _____ eat a balanced diet. (Check one.)Relaxing. I relax by __________.. I like relaxing alone _____ or with other people ____. (Check one.)After this activity, I always feel calm and peaceful. ___________________________________.(http://www.discoveryeducation.com/teachers/free-lesson-plans/self-esteem.cfm)

Advertising Activity: In this activity, students review the messaging contained in advertisements and

commercials to assess the potential impact on – and manipulation of – self-esteem. Take a few minutes to have the group members go through the magazines and tear out

advertisements that attract their attention. Identify as a group the feelings that the advertisement is supposed to elicit, and the

impact of the advertisement on someone with low self-esteem(www.ehow.com/info_799386_adolescent-self-esteem-activities.html

Now ask students to take the information they learned about themselves from the personal inventory, as well as what they learned from the advertising activity, and create a drawing, collage, or short essay that illustrates who they are. Make available paper, art supplies, and magazines to cut up. Give students about 20 minutes to complete their projects.

Coping Skill: Introduce HALT. Go back to advertising and ask which of these advertisements is

designed to make you hungry, which makes you angry (frustrated), which makes you feel lonely or inadequate.

Explain that sometimes we don’t even know that we are being influenced to feel a certain way. On a secret level it is making us feel bad about ourselves. That’s the point of advertising – they give the hope that buying something will make you feel better (retail therapy).

These simple feelings that everyone gets can lead to self-harming perhaps because we are not aware of where our feelings are coming from or how to deal with them.

Next time you become aware of a feeling of being uncomfortable, frustrated, just out of sorts, say the word, “HALT,” and ask yourself these questions:

1. Am I Hungry?2. Am I Angry?3. Am I Lonely?4. Am I Tired?

Now, when you recognize these emotions, does this come from inside of me, am I feeling this, or is it because of something outside of me? If I use HALT, would I still be frustrated? The great way to protect ourselves from these feelings is to eat well, get enough exercise, and get enough sleep. If we take care of ourselves, and we understand what advertisements and commercials are actually trying to do, we have a better perspective, and ultimately higher self-esteem.

Close Session: Revisit the Conscious breathing exercise:

o We are going to see who can count the most breaths. o Have the group members close their eyes and sit in a comfortable position. Ask them

to breathe normally, in through the nose and out through the mouth. Let them take a few breaths.

o Now start counting in your head. Time this exercise for about 3 minutes. o Ask the group members if it was hard to keep counting. Ask them how high they

were able to count? Also ask if the noticed what caused them to be distracted while they were counting.

If it seems to be working for the group and if enough time is left in session, then proceed to part two.

o Now we will do the same thing without counting. Ask the group members to simply focus on their breath this time. After about 5 more minutes close session (it is hard for most beginners to meditate for an extended period).

DBT SKILLS GROUP

Session Six

Time50 minutes

Materials Boxes, balloons (for icebreaker) Paper, lunchbox, pencil case, counselor mindfulness jar Stressballs and journals (for each member to keep)

Objectives This last meeting will focus on reviewing the mindfulness, tolerance distress, and

emotion regulation techniques that have been introduced to the group. The icebreaker will serve as a lesson in trusting another person, as well as establish the member’s own leadership skills.

Ice Breaker Trustwalk

o This activity is an effective team building activity involving leadership and building trust, as blindfolded participants must rely on instructions given to them in order to avoid various obstacles. Counselor finds a large, safe area with minor obstacles, and then prepares the

area with additional obstacles if desired (cardboard boxes, balloons, etc.) As participants to arrange themselves in pairs, one partner guide, one partner

blindfolded Slowly spin blindfolded participant a few times to they don’t know which way

they are headed. Guide participant to field with obstacles. From this point on, only verbal cues

given (i.e. “In approximately five steps, there will be a tree branch, step over it slowly.)

Guide responsible for safety and try hard to steer partner away from obstacles. Group members will learn about the challenge and responsibility for caring

for another person’s well-being; blindfolded partner learns to trust and rely on another person.

(www.icebreakers.ws/team-building/trust-walk-teambuilding-activity.html)

Activity: Story Walkthrough (counselor will have props in place prior to the beginning of session)

o Divide the group into pairs. Give each pair a piece of paper that describes an individual and an action to do. The story will walk through a situation and utilize different skills that they learned from the group sessions. Once the pairs complete the story, they will share the story with a group.

Story #1A. Maria is excited to come to school today. She wanted to see her best friend Jessica and talk

about the movie she saw this past weekend. When Maria saw Jessica in the classroom, but Jessica avoided making eye contact with her and left the room. What are some emotions Maria may be feeling? After discussing the question, go to the

desk and pull out what is inside.B. There is a sheet of paper inside the desk that says STOP.

How would you apply STOP to what Maria is feeling? After discussing the question, go to the teacher’s desk and open the notebook on top of the desk.

C. The notebook will have a sheet that says “helpful people” Sometimes when we are upset about something, talking to someone may help you feel

supported and heard. A teacher is one person you can talk to. Name at least two other people that you can talk to.

Story #2A. Joshua is nervous to come to school today. He has a test and he has studied, but sometimes

draws a blank during the test. Go to the lunchbox on the bookshelf.B. There is a sheet of paper on the outside that reads BREATHE.

Pay attention to your breathe for 15 seconds. How would Joshua feel after breathing? After discussing the question, open the lunch box.

C. There will be a stress ball inside the lunch box. Squeeze the stress ball 10 times. How would Joshua feel after squeezing the stress ball?

Story #3A. Ashley wore her favorite dress to school today. While she was sitting and talking to her friends

Jake and Tara, the class bully Alex knocked her books off her desk and laughed at her. What emotions is Ashley feeling? After discussing the question, go to the teacher’s desk and

open the top right drawer.B. There will be a Mindfulness Jar.

How can Amanda use the mindfulness jar? After discussing the question, go to the backpack.

C. There will be a note taped on an empty journal that reads “Write it out” and the question “What would Amanda write about the situation?”.

Story #4A. Matt overslept so he rushed to class just as the bell rang. He is out of breath in his seat. His

friend Sam tries to give him a high five for making it to class on time, but Matt rolls his eyes. What emotions do you think Matt is feeling since he rushed to class? After discussing, go to the third desk and take out the pencil case.

B. Inside the pencil case will be a piece of paper that reads “HALT. How could Matt apply HALT to this situation?”. After discussing the question, go to the

door.C. There will be a note taped to the door that reads “What are some ways Matt can prevent this

frustrating situation from happening again?”

Compliment List: Write each member’s name on top of a sheet of lined paper. Pass the paper around the

group and have each member write something positive about the person that the paper belongs to.

Alternatively, if members are comfortable, have the group members send their journals around the circle to record their compliments where the members have easy access to them.(www.ehow.com/facts_5482203_self-esteem-activities-kids.html)

Close Session: Revisit the Conscious breathing exercise for the last time – encourage the group members

to continue to perfect the exercise at home, at school, on the bus, on the playground…o We are going to see who can count the most breaths. o Have the group members close their eyes and sit in a comfortable position. Ask them

to breathe normally, in through the nose and out through the mouth. Let them take a few breaths.

o Now start counting in your head. Time this exercise for about 3 minutes. o Ask the group members if it was hard to keep counting. Ask them how high they

were able to count? Also ask if the noticed what caused them to be distracted while they were counting.

If it seems to be working for the group and if enough time is left in session, then proceed to part two.

o Now we will do the same thing without counting. Ask the group members to simply focus on their breath this time. After about 5 more minutes close session (it is hard for most beginners to meditate for an extended period).

OUTCOME EVALUATION

Please answer the following questions on a scale of 1 (Strongly Disagree) to 5 (Strongly Agree).

                                   Strongly         Unsure       Strongly                                   Disagree                           Agree                            1. Overall, I enjoyed the group. 1 2 3 4 52. I will be able to use what I learned in the group. 1 2 3 4 53. I liked the way the leader taught us the skills. 1 2 3 4 54. I understood the skills taught by the group leader. 1 2 3 4 55. I think this group would be good for other kids 1 2 3 4 58. I have already used one or more of the skills I learned in the group outside of the group

1 2 3 4 5

9. I feel better knowing other kids my age also sometimes hurt themselves and I am not alone.

1 2 3 4 5

10.  Doing the homework helped me learn the skills 1 2 3 4 511.  The skills are important to learn 1 2 3 4 512.  Reviewing the homework helped me learn the skills. 1 2 3 4 513.  The role-playing activities were fun 1 2 3 4 514.  Role-playing helped me learn the skills 1 2 3 4 515. I liked learning mindfulness skills 1 2 3 4 516.  I will use mindfulness skills 1 2 3 4 517.  I feel better about dealing with stress and negative emotions

1 2 3 4 5

18.  I will use one of the alternatives to self-harm next time I want to hurt myself.

1 2 3 4 5

19.  I think the alternatives to self-harm will work 1 2 3 4 520.  I will or have used STOP 1 2 3 4 521.  I will or have used DISTRACT 1 2 3 4 522.  I feel better about myself than before the group 1 2 3 4 523. I felt safe sharing in the group 1 2 3 4 524. I wish the group was longer 1 2 3 4 525. I had enough time to learn the skills 1 2 3 4 5

Did you have a favorite activity? If so, what was it?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is there anything you did not like or that you think should be changed?

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are there any of the skills you think you need more help learning?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is there anything else you want to say about the group?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ONLINE RESOURCES FOR GROUP MEMBERS AND PARENTS/GUARDIANS

1. www.psychcentral.com/lib/teens-who-self-harm/0001962

Article specific to teens who self-harm, but also a cite with links to other articles and

issues

2. www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families_Pages/

Self_Injury_In_Adolescents_73.aspx

Website with information about self-injury in adolescents and what parents/teens can to

about self-injury

3. www.thebalancedmind.org/learn/library/self-injury-awareness-for-parents

Website for children with mood disorders. Explains self-injury, how to treat, and provides

resources

Alternatives to physical harm: ice cube, cold shower, rubberband, draw wounds with red

magic marker

Alternatives that do not cause pain to reduce tension and stress: exercise, journaling,

music, hobby using hands, squeezing stress balls, harmless aggressive activities

(throwing ice cubes at wall, eggs in shower, tearing up phone book, punching pillows),

relaxation techniques

4. Stopping the Pain: A Workbook for Teens Who Cut and Self-Injure. Shapiro, L. (2008)

5. McKay, M., Wood, J., Brantley, J. (2007). The Dialectical Behavior Therapy Skills

Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness,

Emotional Regulation & Distress Tolerance. Oakland, CA: New Harbinger Publications, Inc.

6. self-injury.net

7. *1-800-DON’T-CUT – More info on self-injury

8. *http://www.selfinjury.com – Referrals for therapists and tips for how to stop.

9. *1-800-273-TALK – A 24-hour crisis hotline if you’re about to self-harm or are in an

emergency situation.

10. *To Write Love On Her Arms (http://www.TWLOHA.com) - A non-profit movement

dedicated to presenting hope and finding help for people struggling with depression,

addiction, self-injury, and suicide.

11. *1-800-SUICIDE – Hotline for people contemplating suicide.

12. *1-800-334-HELP – Self Injury Foundation’s 24-hour national crisis line.

13. *1-800-799-SAFE – Domestic violence hotline.

14. *1-877-332-7333 – Real Help For Teens’ help line.

ONLINE RESOURCES FOR GROUP LEADERS

Choate, L. H. (2012). Counseling adolescents who engage in nonsuicidal self-injury: A dialectical behavior therapy approach. Journal of Mental Health Counseling, (34)1, 56-71.

Fiorillo, J., & Long, J. (2012). Dialectical behavior therapy skills groups in schools: A review of empirical findings. American Psychological Association, APA Division 16: School Psychology. http://www.apadivisions.org/division-16/publications/newsletters/science/2012/07/empirical-findings.aspx

Perepletchikova, F., Axelrod, S.R., Kaufman, J., Rounsaville, B.J., Douglas-Palumberi, H., & Miller, A. L. (2011). Adapting dialectical behavior therapy for children: Towards a new research agenda for paediatric suicidal and non-suicidal self-injurious behaviours. Child and Adolescent Mental Health (16)2, 116-121.

ISSUES IN APPLICATION

One of the strengths of this group plan is in its applicability to early adolescents. The

plan is easily implementable, as the group leader needs only to follow the steps for the various

activities, and this format lends itself to creativity. Almost any of the activities and exercises

could be substituted for one more suited to the leader’s strengths and interests as long as the

basic domains of the different skills and subject matter are addressed. A 10-12 session group

could be developed using this group as a model to more thoroughly introduce skills and address

adolescent’s concerns. However, even in a six-session group plan, students will be able to learn

some basic skills and engage in social learning (Perepletchikova, Axelrod, Kaufman,

Rounsaville, Douglas‐Palumberi, & Miller, 2011). This model could be adapted for use in

multiple settings; we propose that these skills may be useful for any adolescents in this age

group, and not just those at risk for self-harm.

Still, there could be obstacles in implementing this group. A major obstacle and ethical

concern is found in identifying or advertising for individuals who may participate in the group

while keeping confidentiality. Identifying, gaining the consent of, and engaging individuals in

the group, while keeping the purpose of the group and/or the identity of individuals in the group

private might be difficult. Because these students will likely have to take time away from other

school activities, or stay after school in order to participate, it may be difficult to prevent their

peers from noticing these changes in members’ routines. Also, regardless of rules regarding

confidentiality and steps taken to assure anonymity, it will likely not be within the power of

group leaders to prevent threats to anonymity from individual participants themselves. One

challenge will be in creating a group that can approach this sensitive issue without potentially

stigmatizing group members by setting them apart from their peers.

Another issue will be in effectively delivering the content to members. One problem with

the six-session format is that this short-term model demands perfect attendance to truly be

effective. Because the subject matter is so compressed to fit this time limit, a single absence may

result in a member missing an essential skills session that builds upon previous content or

informs the rest of the group sessions. Also, because of the intensive nature of a short-term skills

development group, individuals with lower cognitive ability may be at a disadvantage or unable

to benefit from the six-session format. Those who have issues with social anxiety, or are simply

introverted or slow to warm up, may also be at a disadvantage in that they will need to be willing

to participate almost immediately to obtain the benefits of the group. These factors may need to

be considered in the screening process, but excluding willing members based on these criteria

may also be unethical unless an alternative group is available. A final ethical concern is that

group members might feel unfulfilled with the short-term format, and may desire to continue

with the group beyond the six sessions offered. Perhaps ending the group at six-sessions would

be denying them their full potential for growth and skills development.

Although Research suggests that DBT is applicable across cultural lines, there may still

be cultural concerns in the application of this group (Reynolds & Linehan, 2002; Seligman &

Reichenberg, 2010). A school setting might likely result in culturally diverse group membership,

and attitudes toward disclosure differ between different cultural groups. There must be some

consideration of cultural norms for members in the group before entering into more intimate

discussions and sharing activities. Also, discussion of individuals’ motivations or triggers for

self-harming behavior may elicit information individuals do not wish to share. This may be

particularly true if the individual is hesitant to disclose a non-traditional family dynamic,

socioeconomic status, minority sexual orientation, etc. As mentioned before, cognitive ability or

development may be a factor, and delivering content to members with a learning disability or a

developmental disorder without stigmatizing them within the group may be challenging or

impractical. Some of the activities may also be difficult for individuals with physical disabilities,

and the setting or curriculum may have to be tailored for these members.

Despite a number of potential obstacles to implementation of this group model, it is still a

potentially valid way to deliver DBT skills development training to this age group. Many of

these considerations may be accounted for in the screening process, and others may be solved for

through minor alterations in group setting and activities. If this model is used as a guideline for

structure and the sessions’ content are viewed as suggestions for delivery of material and

promotion of group process, then the group leader may be able to tailor the model to the needs of

a group with specific demographics or concerns.

REFERENCES

Berk, L. E. (2010). Development through the lifespan. (5th ed.). Boston, MA: Prentice Hall.

Choate, L. H. (2012). Counseling adolescents who engage in nonsuicidal self-injury: A

dialectical behavior therapy approach. Journal of Mental Health Counseling, (34)1, 56-

71.

Fiorillo, J., & Long, J. (2012). Dialectical behavior therapy skills groups in schools: A review

of empirical findings. American Psychological Association, APA Division 16: School

Psychology.

Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New

York, NY: Guilford Press.

McKay, M., Wood, J., Brantley, J. (2007). The Dialectical Behavior Therapy Skills Workbook :

Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness,

Emotional Regulation & Distress Tolerance. Oakland, CA: New Harbinger Publications,

Inc.

McMahon, E. M., Corcoran, P., McAuliffe, C., Keeley, H., Perry, I. J., & Arensman, E. (2013).

Mediating effects of coping style on associations between mental health factors and self-

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Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of

adolescent non-suicidal self-injury and deliberate self-harm. Child And Adolescent

Psychiatry And Mental Health, 6doi:10.1186/1753-2000-6-10

Neacsiu, A.D., Rizvi, S.L., & Linehan, M.M. (2010). Dialectical behavior therapy skills use as a

mediator and outcome of treatment for borderline personality disorder. Behaviour

Research and Therapy, 48, 832-839. doi:10.1016/j.brat.2010.05.017

Perepletchikova, F., Axelrod, S. R., Kaufman, J., Rounsaville, B. J., Douglas‐Palumberi, H., &

Miller, A. L. (2011). Adapting dialectical behaviour therapy for children: Towards a new

research agenda for paediatric suicidal and non‐suicidal self‐injurious behaviours. Child

and Adolescent Mental Health, 16(2), 116-121. doi: 10.1111/j.1475-3588.2010.00583.x

Reynolds, S., & Linehan, M. (2002) Dialectical behavior therapy. In Hersen, M., & Sledge, W.

(Eds.), Encyclopedia of psychotherapy (pp. 621-628). New York, NY: Academic Press

Seligman, L., & Reichenberg, L. (2012). Selecting effective treatments: A comprehensive,

systematic guide to treating mental disorders. (4th ed.). Hoboken, NJ: John Wiley and

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Seligman, L., & Reichenberg, L. (2010). Theories of counseling and psychotherapy: Systems,

strategies, and skills. (3rd ed.). Upper Saddle River, NJ: Pearson Education Incorporated.

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Ward-Ciesielski, E. F. (2013). An open pilot feasibility study of a brief dialectical behavior

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