Implementation of Dialectical Behavioral Therapy Skills with Adolescents JENNIFER CONFORTO LMHC, CASAC BRIANNE FEGARSKY LMSW, CASAC-T

Theoretical Overview of Dialectical Behavioral Therapy (DBT)  DBT is a cognitive behavioral treatment that was originally developed to treat chronically suicidal individuals diagnosed with Borderline Personality Disorder (BPD).  Research has shown this treatment modality to be effective in treating a wide range of disorders such as substance dependence, depression, post-traumatic stress disorder and eating disorders.  Components of DBT including skills training groups, DBT individual therapy and DBT therapist consultation. (

Biosocial Theory  Biosocial theory suggests that behaviors of adolescents with suicidal/self-injurious behaviors stem from a combination of biological and environment factors. “Specifically these factors are emotion dysregulation (mostly biological in origin) and invalidating environments (where inadequate emotion regulation coaching and dysfunctional learning take place.” (Miller, Rathus, Linehan, 2007)

Biosocial Theory Continued  An invalidating environment is defined by the tendency to negate and/or respond erratically and inappropriately to private experiences.

DBT Treatment Target Hierarchy  Pre-treatment stage  Stage 1

Treatment Target Hierarchy Continued  Stage 2  Stage 3  Stage 4

Common Self-Destructive Coping Behaviors  Eating Disorders Anorexia, Bulimia, Overeating  Self-Harm Behavior Self-Mutilation (cutting, burning, scratching), suicide threats, suicide attempts  Substance Abuse/Dependence  Alcohol, Illegal Drugs, OTC Drugs, Prescription Drugs  Avoidance Denial, Oversleeping, Procrastination, Stuffing Emotions, Isolation  Physical Aggression Towards People, Animals, Objects, and Property  Verbal Aggression Threatening Remarks, Telling People Off, Temper Tantrums  Other Criminal Acts, Gambling, Habitual Lying, High Risk Behavior, Over-shopping, Promiscuity

5 Modules of DBT  Mindfulness

Mindfulness  Goal of mindfulness module is to teach participants to be open-minded and in the moment  Create non-judgement thought processes that reduce suffering  Increase awareness of self and others  Increase of attention and impulse control

Mindfulness “What” Skills Observe: without words, noticing, sensing, and attending Describe: apply verbal labels Participate: without self-consciousness, with attention

Mindfulness “How” Skills Nonjudgmentally: do not evaluate One-mindfully: focus on one activity at a time, with awareness Effectively: doing what works-what helps reach goals

Mindfulness – 3 States of Mind

5 Modules of DBT  DISTRESS TOLERANCE

Distress Tolerance  Goal of this module is to help participants tolerate difficult situations and painful emotions  Acceptance of situations as they are  Willingness vs. Willfulness

Distress Tolerance  Crisis Survival Skills  Wise Mind “ACCEPTS”  Self-soothing with six senses  IMPROVE the moment  PROS and CONS  TIPP

5 Modules of DBT  Interpersonal Effectiveness

Interpersonal Effectiveness  When to use interpersonal effectiveness skills:  When trying to balance priorities  Balancing wants vs should

Goals of Interpersonal Effectiveness (Seth Axelrod, 2008)  Self-Respect Effectiveness  Objectiveness Effectiveness  Relationship Effectiveness

Interpersonal Effectiveness Overview  Attending to Relationships  Building Mastery and Self-Respect

OBJECTIVE EFFECTIVENESS (LINEHAN, M., 1993)  DESCRIBE- STICK TO FACTS. DESCRIBE CURRENT SITUATION AND WHAT SPECIFICALLY YOU ARE REACTING TO.  EXPRESS- YOUR FEELINGS AND OPINIONS ABOUT THE SITUATION  ASSERT- ASK FOR WHAT YOU WANT AND SAY NO CLEARLY.  REINFORCE- EXPLAIN CONSEQUENCES. POSITIVE EFFECTS OF GETTING WHAT YOU WANT/NEED AND NEGATIVE EFFECTS OF NOT GETTING IT

OBJECTIVE EFFECTIVENESS (LINEHAN, M., 1993)  M STAY MINDFUL (BROKEN RECORD/IGNORE)  APPEAR CONFIDENT  NEGOTIATE (TURN TABLES)

Relationship Effectiveness  GENTLE- BE GENTLE, NO ATTACKS, NO THREATS, NO JUDGING  INTERESTED- ACT INTERESTED, LISTEN  VALIDATE- OTHER PERSON’S FEELINGS  EASY- USE AN EASY MANNER

Self-respect Effectiveness  FAIR- BE FAIR TO BOTH YOU AND OTHER PERSON  APOLOGIES- DO NOT BE OVERLY APOLOGETIC  STICK-TO YOUR OWN VALUES  TRUTHFUL-DON’T LIE, DON’T MAKE UP EXCUSES

Factors That Reduce Interpersonal Effectiveness  LACK OF SKILL  MYTHS THAT YOU BELIEVE  EMOTION MIND  INDECISION  ENVIRONMENT

Communication Skills Building  Communication Styles  Passive  Aggressive  Assertive

Tips For Assertive Communication  Focus on the issue not the person - 80/20 rule  Use "I" statements  Be solution oriented  Take a break if needed

DBT 5 Modules Continued  Emotion Regulation

Emotion Regulation Helps monitor emotion dys-regulation Involve labeling and understanding emotions Helps break patterns of mood-dependent behavior and cycle of suffering

Emotion Regulation Goals of Emotion Regulation Training  Understand/identify functioning of emotions and emotional experiences  Reduce emotional vulnerability  Decrease frequency of unwanted emotions  Decrease emotional suffering (reduce shame, anger, guilt and anxiety)

Emotion Regulation  Opposite Action  Building Mastery  Cope Ahead  Ride the Wave

Emotion Regulation Treat P hysica L illness Balance E ating A void mood-altering drugs Balance S leep Get E xercise

 Middle Path

Middle Path  Decreases polarized thinking  In dilemmas; two opposing view points can be valid and true  Encourages exploration of middle ground and compromise  In family dynamics: being too rigid vs. too permeable, fostering independence vs. dependence

DBT Skills Building With Adolescents  Role Playing is vital to skills learning and demonstration of successful skill use  Role Playing can occur with facilitators, peers and parents often in relation to current interpersonal dilemmas/conflicts  Assists with building confidence in boundary setting and saying “No” when appropriate.  Parent support group learns skills concurrently to re-enforce and integrate skills use in family dynamic

 Homework Example

 Question and Answer ?

References  Linehan, M. Skills Training Manual for Treating Borderline Personality Disorder P  Miller, A., Rathus, J., Linehan, M. Dialectical Behavioral Therapy with Suicidal Adolescents. P.45-88,  Rathus, J. and Miller, A. DBT Skills Manuel for Adolescents P 