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 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

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 non- judgementally” –Jon Kabat Zinn

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)

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 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

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 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)