DIALECTICAL
BEHAVIORAL
THERAPY
with children and adolescents with Bipolar and
Borderline Personality Disorder
Ana Schlosser, MS R Psych , LPC, NBCC
atschlosser@gmail.com
Today’s objectives…
• Define DBT and it’s origins
• Who does it work with
• Applications to children and teens
• How it works with Bipolar disorder and Borderline Personality
Disorder
• Learn 4 main priniciples
• Applications to educational environment
Intro to Dialectical Behavioral Therapy
• Created by Marsha Linehan (1993) to treat persons diagnosed with
Borderline Personality Disorder (BPD)
• 1938 Stern “Normal-Neurotic-Psychotic”
• 1956 Rado “extractive disorder”
• 1965 Esser and Lesser “Hysteroid Disorder’
• Current diagnosis of BPD has been present since 1980’s DSM although has
existed and noticed since 1930’s
What is Borderline Personality Disorder?
• 1 frantic efforts to avoid real or imagined abandomnment
• 2 pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation
• 3 identify disturbance: persistent and marked disturbed, distorted
or unstable self image or sense of self (feeling like one is evil or
does not exist)
• 4 impulsiveness in at least two areas that are potentially self
damaging (eg: spending, sex, substance abuse, shoplifting, reckless
driving, binge eating etc)
• 5 recurrent sexual gestures, threats or behaviors or self mutilating
• 6 Affective mood instability-marked reactivity of mood lasting
hours sometimes days
• 7 chronic feelings of emptiness
• 8 inappropriate intense anger or lack of control of anger
• 9 transient, stress related severe dissociative symptoms or paranoid
ideation
According to American Psychiatric Assoc.
• The essential feature of BPD is a pervasive pattern of instability of
interpersonal relationships, self image, and affect and marked
impulsivity that begins by early adulthood is present
• Personality Disorders are not diagnosed in persons who are under
18 years of age…HOWEVER, you can provide a provisional diagnosis
under label AXIS II with Borderline Traits
Bipolar Disorder
• Can be swings between HI and LOWS
• Can be swings between “Normal” and extreme LOWS
• In childen and teens looks A LOT like ADHD but does not respond to
ADHD medications
• Looks like ADHD in HULK mode
Why was DBT Created?
• Because people with BPD suffer constantly from emotional crisis
• They lack skills to cope
• Curriculum based
• Due to intense needs of these clients require a lot of maintenance
• Other behavior therapies focus a lot on change…DBT is acceptance
• Sets limits with their attention seeking
• Respond to crisis vs reacting
• Consistent amongst providers to minimize triangulation
• Helps therapist with reciprocal influence
DBT’s Creation
• Based on Cognitive Behavior Therapy (but on steroids)
• Created specifically for BPD
• “Dialectics” understanding of the relationship between reality and
relationships.
• Goal is acceptance and change
• BIO SOCIAL THEORY BPD is the result of emotional dysregulation
and invalidating environments
DBT VS OTHER BEHAVIORAL THERAPIES
Similarities
Differences
CBT
TARGETING (PRIMARY, SECONDARY
THREATS)
THERAPIST RECIPROCAL VULNERABILITY
COMMITMENT STRATEGIES NO HARM
CONTRACTS
EXPOSURE & RESPONSE PREVENTION
MINDFULLNESS AS SKILL SET
SKILLS TRAINING & STIMULUS
DIALECTIC FOCUS
DISTRESS TOLERANCE
REINFORCEMENT
EMOTIONAL REGULATION/OPPOSITE
ACTION
TELEPHONE CONSULTATION
IRREVERENCE
VALIDATION AS A SKILL SET
DBT AND RELATIONSHIP
• BELEIVING IN THE PHILOSOPHY IS CRITICAL
• DETERMINES THE ATTITUDE TOWARDS TREATMENT AND THE
CLIENT
• RELATIONSHIP IS KEY
• RELATIONSHIPS ARE SOMETIMES ALL THAT KEEPS CLIENTS ALIVE
• RELATIONSHIP WITH PROVIDER KEEPS THEM IN THERAPY/SCHOOL
• RELATIONSHIP WITH GROUP KEEPS THEM IN GROUP
requirements
• DBT based off most clients are female
• Must continue in individual therapy as well as group
Assumptions to be made
• Clients are doing the best they can
• They want to improve
• They need to do better, try harder, be more motivated
• May not have caused their own problems but have to solve them
anyway
• Therapy can fail- coaching can occur over phone
• Therapists need support
• Clarity, precision, ad compassion are utmost importance
• Help them change in a way that brings them closer to their goals
• Therapy usually at least 1 year
• DBT FAMILY GROUP
DBT format
• Target prioritize needs
• Life threatening, body damaging, grieving etc
• Prioritize skill sets
• 4 modules-23 skill sets
What do these kids look like?
• Drop out of treatment often
• No sense of urgency from natural environment
• Resist change- complain, target lash out at you
• Self instability of caregiver instability
• Constant aggression or aggressive reactions
• Frequent hospitalizations
• Non compliance with treatment/meds
• Overt emotinoal reactions despite level or degree of stimulus
• People pleasers but burn bridges
• Drains
• Perpetual victims “injustice collectors”
• Lots of partners, drama and or promiscuity
• Don’t always lack skills-may just lack motivation
Typical client characteristics
• If you engage in power struggle you already lost
• Doesn’t pay to be a good client
• Parenting that is too strict or loose
• Suicidal behaviors get validation about emotional pain
Applications to children and adolescents
• If you start treatment early it may prevent BPD
• Biological irregularities combined with dysfunctional environments
solidify negative patterns
• Children and teens exposed to MANY different emotional role
models
• Children especially responsive to behavioral therapy
Targeting and prioritizing
• Primary- life threatening behaviors
• Secondary- parasuicidal
• Third- behaviors leading towards destroying quality of life
• Finally-increase alternative behavioral skills to function better
Invalidating environments
• Respond erratically and inappropriately to private experiences
• Extreme reactions, respond erratically and inappropriately to private thoughts , beliefs, feelings and emotions
• Extreme over or under reaction
• Control negative affect
• Triviailize or punish painful experiences and attribute them to negative trains such as lack of motivation, discipline or
attitude
• Label positive emotions or experiences as lack of judgment, reflection or basic impulsivity
• Over use punishment or abuse to control behavior
• Expect the child to manage self
• Does not teach the child to label private experiences, including emotions, or understand normal emotions or how to
modulate emotional arousal/regulation
• Some Children are born able to regulate and modulate emotions so invalidating environments don’t have as much effect
on them.
• Children who have difficult temperaments AND are emotionally vulnerable, invalidating environments have
DEVASTATING effects on them
• Estimated 75% of Borderline Personality Disordered clients have sexual trauma in their history. However, Sexual Trauma is
NOTneccessarily a predictor of Borderline personality Disorder
Linehan’s 6 behavior Problem Patterns in BPD
• 1-Emotional Vulnerability- drowning in emotions with no control
• 2-Self Invalidation- “my thinking is screwed up” (beat self up)
• 3-Unrelenting Crisis- Extreme Lack of Coping
• 4-Inhibited Grieving- not being able to grieve losses
• 5-Active Passivity-Intense defeat and dispair. Want the environment
to take care of emotions for them, avoid therapy, awol, self harm
• 6-Apparent Competence-lack emotional intelligence, façade of
capacity
EMOTIONAL VULNERABILITY
• Patterns of difficulty regulating negative emotions including
• high sensitivity to negative emotional stimuli
• High emotion intensity
• Slow return to emotional baseline as well as awareness and experience emotional
vulnerability
• May include tendency to blame social environment as having unrealistic expectations and
demands
• Get very upset about little things and take long time to calm
• Have difficulties with partings
• These are the dramatic people of the world
• Slight embarrasment=deep humiliation
• Annoyance=rage
• Shame=guilt
• Apprehension=panic or incapacitating fear FIGHT FLIGHT FREEZE
• Often forget or cannot identify why they got so upset to begin with
• How do you help?
• -(do chain analysis and focus ONLY on what the child has control over)
SELF INVALIDATION
• Tendency to invalidate or fail to recognize ones own emotional
responses, thoughts, beliefs, behaviors.
• Unrealistically high standards and expectations for self
• May include intense shame, self hate, and self directed anger
• Come from invalidating environments
• These kids do not trust themselves or feel capable
• When told to stop or don’t they don’t know how.
• Way to help is to use a cognitive model
UNRELENTING CRISIS
• Pattern or frequent, stressful, negative environmental events, disructions,
and road blocks. Sometimes caused by their dysfunctional lifestyle, others
by inadequate social milieu and many by fate or chance.
• These kids ALWAYS “need to talk”
• In constant emotional crisis-frequent fliers to the counselor office
• Only options are to survive or solve their problem
• Teach these kiddos about their emotions. Teach them to inhibit
inappropriate behavior thru problem solving:
• 1 what is the problem
• 2 what are some possible solutions
• 3 for each solution ask:
• Is it safe, is it fair, will it work?
4 Choose a solution and use it
ask self: is it working? If not, what else could I do?
INHIBITED GRIEVING
• Tend to inhibit and over control negative emotional responses,
especially those associated with grief and loss, including sadness,
anger, guilt, shame, anxiety and panic
• Help them by teaching them to make lists on how to handle life or
areas of life
ACTIVE PASSIVITY
• Tend to be passive regarding interpersonal problem solving styles,
involve failure to engage actively in solving own life’s problems,
often together with active attempts to solicit problem solving from
others in the environment, learned helplessnes, hopeless,
helicopter parenting (?)
• These are the “yeah…but…” kids
• USE A PROBLEM SOLVING MODEL with this kids too!
APPARENT COMPETENCE
• Tendency for the individual to appear deceptively more competent
that what they actually are. Usually due to the failure of
competencies to generalize across expected moods, situations,
time and to fail to display adequate, non-verbal cues of distress
• These kids are USUALLY quite bright and present well but poor
follow thru
• Teach them to co-regulate with guidance of healthy models
Growing in to adults
• As children, BPD clients adopt the characteristics of the invalidating
environment
• They invalidate their own emotional experiences, look to others for
accurate reflections of external reality and oversimplify the ease of
solving life’s problems
• This leads to unrealistic goals and self hate following failure to
achieve these goals
• The shame reaction is a natural result of a social environment that
shames those who express emotional vulnerability
A problem to consider…
• BPD clients (especially teens) is that they get upset and STAY upset
(poor self regulation)
• They become obsessed with their thinking, their anger, the way
they have been wronged and cannot let it go
• They need to learn they are sometimes wrong or make mistakes
and it doesn’t change their value or worth
• They need help with their state of mind
• To let go they have to learn to watch and learn to connect thoughts
with feelings. But first you have to watch to determine whether
they understand their feelings
• WHAT DO YOU FOCUS ON TO TEACH THIS?.....
4 Main DBT Principles
• Interpersonal effectiveness (change based)
• Emotional Regulation (change based)
• Distress Tolerance (acceptance based)
• Mindfulness (acceptance based)
• These are derived from Zen philosophy due to it’s focus on
validation and acceptance of “what is” of one’s experience
through meditative techniques for creating awareness and
acceptance. Noticine what is happening in your body and mind.
• “Pay attention, on purpose, in the present moment nonjudgementally” –Jon Kabat Zinn
INTERPERSONAL EFFECTIVENESS
• Assertiveness and Communication Training
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Teach them how to respectively ask for what they want
How to say no to what they don’t want
To have an opinion taken seriously even when others do not agree
How to build respect
How to get and keep a relationship they value
DEAR MAN, GIVE FAST
Describe, Express, Assert, Reinforce (get what I want)
Stay Mindful, Appear confident, Negotiate
Be Gentle, act Interested, Validate, use an Easy manner (keep the
relationship)
Be Fair, no Apologies, Stick to values, be Truthful (keep self respect)
EMOTIONAL REGULATION
• Goal is to identify and understand purpose of emotions. Reduce
vulnerability to emotions, Decrease emotional suffering by:
• Recognize emotions, keep emotional records, recognize self destructive
behaviors, separate thoughts from behaviors
• Advanced Skills of being mindful of emotions without judgement, emotion
exposure, teach opposite action
• Distract from emotions with ACCEPTS
• Activities=Activity Card ( plan day in a.m. and p.m
• Contributing= contribution card (these are things I can do to distract myself)
• Comparisons= Comparison (find stories of those worse off)
• Emotions= do something that will create opposite emotion
• Push away-make a list of the stressors, mark out ones that you don’t have control
over and push the rest away in a box
• Thoughts- do thought distraction tass (counting, tv, puzzles, game apps_
• Sensations-Use the 5 senses to distract (self soothing boxes, ice, water, ipod,
stress ball, lotion hands etc)
DISTRESS TOLERANCE
• In crisis, people are often more interested in getting validation of how bad
their situation is rather than surviving the situation. This NEVER fixes
things. Do NOT allow them to ramble more than 5-10 mins about the
problem and teach stress tolerance skills
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Self sooth with the 5 senses- self soothing boxes
Sight-art, pics of families, pics of self as babies, tv, nails, makeup
Sound-music, nature, hum, books on tape, affirmations
Smell- candle, lotion, potpourri, nature
Taste-chocolates, peppermints, drinks, sweet tarts, spicy candies
Touch- wash rag, lotion, baths, brush hair, hug, feel furniture/fabric
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RADICAL ACCEPTANCE
PLEASURABLE ACTIVITIES
DISTRACTION
Watch for mood dependent behavior-meaning they do the behavior because of the type of mood
they are in. This is more of an expression of the mood than a specific goal or purpose eg: kill the
messenger
Advanced Distress Tolerance
• IMPROVE THE MOMENT
• Imagery
• Meaning-make lemonade out of lemons, set goals, create meaning
• Prayer-spirituality, wise mind, serenity prayer
• Relaxation-PMR, deep breathing, Cranial Nerve 7
• One thing-focus on one thing at a time-build awareness
• Vacation- mini breaks, breathers, escape
• Encouragement-cheerleader, affirmation statements,collages, song
• SAFE PLACE VISUALIZATION
• CUE CONTROLLED RELAXATION
• HIGHER POWER ACTIVITIES
TIME OUT
• HERE AND NOW
MINDFULNESS
• The goal is to become aware of and notice thoughts only
• Honor the feeling
• This distracts by focusing on the awareness process vs stressful thought
itself
• Emotions are very powerful so they can’t do this as long
• LETTING GO: imagine sitting on a river bank, let emotions go out to sea
with each wave without getting caught in the wave or torrent of the
emotions
• THOUGHT DIFFUSION
• RECORD 3 MINS
• INNER OUTER EXPERIENCE
BAND OF LIGHT FEELING CONTINUUM
• FOCUS ON A SINGLE OBJECT
• FOCUS SHIFTING
• DRAW/DESCRIBE YOUR EMOTIONS
• MINDFUL BREATHING
MINDFULNESS
• Emotional Mindfulness advanced skills are:
• Wise mind meditation, negative judgments, beginner’s mind,
judgment diffusion, judgments vs present moment, I statements,
doing what’s effective, daily mindfulness as a prevention, yoga
• Kindness and compassion, spaciousness and stillness/
Increase positive emotions
• SHORT TERM
• -Do + things that are possible now
• Increase pleasant activities that prompt + emotions
• Do at least 1 thing a day that is pleasant
• LONG TERM
• Make changes in your life so that + things are more likely to occur
• Make a list or find a list of + activities to check off
• Do a sleep diary focusing on sleep hygiene
• Attend to relationships (mend, reach out, work on)
• ALL OF THE ABOVE HELP WITH EMOTIONAL REGULATION
TALE OF 2 MINDS
DOING Mind-busy
BEING Mind-relaxing
Westernized Cultures
watches
Monkey mind
Observe without interpretation
Uses brain
emotional
Head approach
Little to no thinking, just experiencing
All about info and facts
Uses senses
Rational and realistic/unrealistic
Self empowering
Focused on future and plans
Here and Now
prevention
No goal in mind
Wander, obsessive, ruminating
focused
QUICK LIST OF INTERVENTIONS
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No harm paper contracts
Negative replacement skills for harm reduction (rubber bands, red ink)
Positive data logs
Functional chain analysis
Activity scheduling
Thought and emotional records
15 mins of mindfulness-watch bubbles, other distractions
Worry warts wastebaskets
Mindfulness with a raisin, m & m, mint etc
Letter writing
Old rag dolls
Feelings faces
I messages
Feelings charades
Talk to the hand- 5 people who lift up and 5 people who hold down
Positive memory books
Memory candles
Problem solving role plays
Listening and reflecting scenarios
Listening and communication blocks
RESOURCE & REFERENCE GUIDE
• Dialectical Behavior Therapy with Suicidal Adolescents-Miller, Rathus,
Linehan 2007
• Don’t Let Your Emotions Run your Life
• Bodily Harm-Conterio& Lader
• Treating Self Injury-Walsh
• Cognitive Behavior Therapy for Borderline Personality Disorder-Linehan
1991
• Skills Training Manual for Treating Borderline Personality Disorder-Linehan
1993
• The Dialectical Behavior Therapy Skills Workbook-McKay, Wood, Brantley
2007
• Recommended Readings:
• Sometimes I Act Crazy (for BPD)
• Stop Walking on Eggshells (for those who care for BPD)