1. Dialectical Behavioral Therapy
with children and adolescents with Bipolar and Borderline Personality Disorder
Ana Schlosser, MS R Psych , LPC, NBCC

2. 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

3. 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

4. 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. 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

6. 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

7. 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

8. 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

9. 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

10. DBT VS OTHER BEHAVIORAL THERAPIES
Similarities
Differences
CBT
THERAPIST RECIPROCAL VULNERABILITY
TARGETING (PRIMARY, SECONDARY THREATS)
COMMITMENT STRATEGIES NO HARM CONTRACTS
EXPOSURE & RESPONSE PREVENTION
MINDFULLNESS AS SKILL SET
SKILLS TRAINING & STIMULUS
DIALECTIC FOCUS
DISTRESS TOLERANCE
REINFORCEMENT
IRREVERENCE
EMOTIONAL REGULATION/OPPOSITE ACTION
TELEPHONE CONSULTATION
VALIDATION AS A SKILL SET

11. 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

12. requirements DBT based off most clients are female
Must continue in individual therapy as well as group

13. 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

14. DBT format Target prioritize needs
Life threatening, body damaging, grieving etc
Prioritize skill sets
4 modules-23 skill sets

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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?

24. 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

25. 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!

26. 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

27. 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

28. 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?.....

29. 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 non- judgementally” –Jon Kabat Zinn

30. INTERPERSONAL EFFECTIVENESS
Assertiveness and Communication Training
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)

31. 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)

32. 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
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
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

33. 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

34. 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

35. 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/

36. 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

37. 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

38. QUICK LIST OF INTERVENTIONS
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

39. 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)