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Dialectical Behavior TherapyDialectical Behavior Therapy

One very effective approach and method I offer children and their families is Dialectical Behavior Therapy (DBT).

What is Dialectical Behavior Therapy?

DBT was pioneered by Dr. Marsha Linehan. The therapy was designed to help adults who were suicidal and who struggled with self-harm. It has now become the treatment of choice for individuals with Borderline Personality disorder (BPD). Generally those with BPD have a pattern of unstable relationships, have an unstable self-image, engage in impulsive activity (e.g. sex, substance abuse, spending), engage in recurrent suicidal behavior and/or self-harm, have intense emotional instability, have feelings of emptiness, have difficulty controlling anger, and can have stress-related paranoid ideation (Please see below for the DSM-IV criteria for BPD). DBT has assisted many adults who have BPD to be more successful and happy in their lives.

Since its original use DBT has been modified to treat a number of mental health problems. It is now being used to treat drug addiction and eating disorders. It has also been modified to assist very troubled adolescents who fit a number of the criteria for Borderline Personality Disorder. Adolescents under the age of 18 years cannot be diagnosed with BPD but they can demonstrate several of the characteristics of BPD. The goal of offering DBT to adolescents is to assist them in learning coping strategies, prevent a later diagnosis, and to help them feel more stable and content with their lives. It can also offer an adolescent’s family with new ways to assist their family and their adolescent.

What types of problems are treated by adolescent DBT?

Adolescents cannot be diagnosed with BPD but they can show many of the characteristics of those adults with BPD. Below the criteria for Borderline Personality is laid out for you according to the DSM-IV. When you see a therapist who is trained in adolescent DBT they would consider the DSM-IV criterions to determine if adolescent DBT would be the best fit for an adolescent. In addition to the DSM-IV criteria and historical information collected some psychologists may perform a Millon Adolescent Clinical Inventory (MACI) or Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A) to assist them in determining an adolescent’s appropriateness for DBT.

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. Note: Does not include suicidal or self-mutilating behavior covered in Criterion 5.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and sense of self.

3. Identity disturbance: Markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger (e.g. frequent displays of temper, constant anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

What does DBT look like?

Adolescent DBT is relatively new. The program I follow within private therapy was designed in Sussex, New Brunswick at the local Mental Health center. It follows is a 13 week closed program. An adolescent who fits the characteristics would participate in group and individual therapy. A family member would also participate in the group with the adolescent.

The first few sessions would consist of gathering historical information and possibly completing formal assessments. The sessions would also focus on developing the adolescent’s and family’s commitment to the therapy.

The adolescent along with one family member would engage in a weekly 2 hour group session. The group is designed to teach skills and coping strategies in the following areas: Mindfulness, Emotional Regulation, Distress Tolerance, Interpersonal Effectiveness, and Walking the Middle Path.

Mindfulness:A “core” DBT skill, mindfulness involves paying attention, in the moment, non- judgmentally to live your life in a deliberate manner

Emotion Regulation: Learn the function of emotions and improve your ability to describe, change, and cope effectively, rather than let emotions control you

Distress Tolerance: Manage crises without making your problems worse

Interpersonal Effectiveness: Attend to your needs and improve relationships

Walking the Middle Path: Learning to think in a way that will help you get what you need but keep your emotions, your relationships, and you in a more balanced place

The adolescent would also engage in 1 hour of individual therapy weekly to review diary cards and to address individual issues and application of skill development.

Why choose DBT?

Adolescents who fit the criteria for DBT are in misery and most often their families are struggling along with them. Adolescent DBT can offer them a new way to think and new coping strategies to apply to his or her life. It can also provide the adolescent’s family an opportunity to learn new skills, and new ways to both support and respond to their adolescent.

There are two important factors to consider:

1) Borderline Personality is not normally diagnoses before the age of 18 years. An adolescent’s personality is believed to still be in the midst of development and personality traits are believed to change. As a result, adolescent DBT offers a therapy to assist struggling adolescents an opportunity to learn new ways of coping, viewing situations, viewing self and interacting with others.

2) Addressing mental health issues in adolescents has proven to be helpful and minimize, if not prevent, the occurrence of a mental health issues in adulthood.

What research tells us about DBT?

Katz, L. Y., & Cox, B. J. (2002). Dialectical behavior therapy for suicidal adolescent inpatients: A case study. Clinical Case Studies, 1, 81-92.

Miller, A. L., Glinski, J., Woodberry, K., Mitchell, A., & Indik, J. (2002). Family therapy and dialectical behavior therapy with adolescents: Part 1, Proposing a clinical synthesis. American Journal of Psychotherapy, 56 (4), 568-584.

Miller, A. L., Rathus, J. H., Linehan, M. M. Wetzler, S., & Leigh, E. (1997). Dialectical behavior therapy adapted for suicidal adolescents. Journal of Practical Psychiatry and Behavioral Health, 3, 78-86.

Miller, A. L., Wyman, S. E., Glassman, S. L., Huppert, J. D., & Rathus, J. H. (2000). Analysis of behavioral skills utilized by adolescents receiving Dialectical Behavior Therapy. Cognitive and Behavioral Practice, 7, 183-187.

Rathus, J. H., & Miller, A. L. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide and Life-Threatening Behaviors, 32(2), 146-157.

Turner, R. M., Barnett, B. E., & Korslund, K. E. (1998). The application of dialectical behavior therapy to adolescent borderline clients. In Session: Psychotherapy in Practice, 4(2), 45-66.

Woodberry, K., Miller, A. L., Glinski, J., Indik, J. & Mitchell, A. (2002). Family therapy and dialectical behavior therapy with adolescents: Part 2, A theoretical review. American Journal of Psychotherapy, 56(4), 585-602.