The emergence of DBT in the last decade has resulted in its application for a number of psychological and/or behavioral issues. The original intent of its founder, Marsha Linehan, was to treat patients in hospitals suffering from personality disorders, primarily Borderline Personality Disorder. Research has shown, however, that this type of therapy yields excellent results for anyone struggling with ineffective copings skills or behaviors.

DBT has been modified for the likes of depression, anxiety, substance abuse, as well as adolescent issues. More and more, it has been applied regularly to individuals who experience difficulties involving their relationships. In fact, one of the core modules of DBT is “Interpersonal Effectiveness”, which is essentially copings skills for relationship effectiveness.

For couples who tend to cycle through, or bump up against, the same types of arguments, DBT provides a refreshing approach toward meaningful insight and lasting change, with a unique balance of validation and a challenge to change what one can control.

Structured couples DBT offers a specific curriculum for couples to practice. There is little focus on the couple’s history, but rather significant attention to the here and now, and on what is and isn’t working for the couple. In this treatment approach, the couple commits to a time-limited, goal-oriented plan in which there is a predetermined weekly appointment that focuses on the practice assignments stemming from the four modules of DBT. In this way, there is less focus on the conflict, and more attention to what will work to replace the conflict with optimism.

Couples often convey that their issue is poor “communication.” Couples DBT is enlightening as it examines where the break down exists, and where ineffective patterns inform day to day conflict within the relationship. Couples often appreciate the focus and opportunity to practice learning new communication/coping skills rather than inadvertently clinging to the old, “he said, she said”, and hoping the therapist will become the judge and jury. With DBT, there is no room for judgment. Instead, the therapist observes and describes what is experienced with the couple regarding their interactions, and the educates the couple on what they might attempt instead of the behaviors that lead to hurt.

For more information about couples DBT, please contact Patrick to determine if this type of treatment is appropriate for you and your partner/spouse.

303.909.9054.

Dialectical Behavior Therapy is an evidenced-based effective treatment for adolescents and adults exhibiting emotional instability. Emotion Theory suggests several factors that lead to problematic emotion regulation.

Emotion Theory allows parents to gain a better understanding of how a child’s emotions work, and how the parent can influence changing maladaptive or problematic emotional outburst/reactions.

Parents must first understand that emotions are largely a biochemical process. Neurotransmitters, chemicals in the brain, either increase or decrease the probability that information will be sent (see Marra 2004). Mental health providers will often comment on a “chemical imbalance” when describing a child or adolescents mood states, or emotional responses. Parents must keep in mind that we are biological creatures, reliant on our bodies and chemical processes for reliable and/or predictable functioning. When a biochemical imbalance exists, parents are often perplexed when their child over/under reacts to circumstances that “most” children handle with predictability based on age and development.

Biology is commonly held as the single biggest factor in determining the child’s propensity for extreme emotional over-reactions, or extreme under-reactions, as the case may be. For example, a child with two parents who have experienced mood instability of some sort, is more likely to also struggle with emotions, interpersonal conflict or an intolerance with respect to distress.

Children, as we know, are incredibly resilient, and there are certainly statistics that show that children of two emotionally impaired parents/grandparents exhibit mostly normative emotion regulation. While you cannot control your child’s genetic make-up, you can absolutely effect some change with respect to the child’s environmental factors, or explore appropriate medication with your child’s physician.

Helping your child become more aware of his/her body, and the body’s responses to emotionally provocative circumstances, can be quite influential. Yoga for children has been steadily increasing in recent years. Child-focused yoga helps your child with mindfulness of how his/her brain takes cues from the body about what she/he is experiencing. In my practice, mindfulness and basic yoga techniques are practiced with children between the ages of 7-12. Often, we will complete exercises that prompt an awareness of facial muscles as well. The face, for example, has more muscles that any other single area of the body. While they are not strong muscles, they are instead exquisitely delicate muscles that can produce hundreds of facial changes (see Marra, 2004). Children learn the difference between happy/sad/angry faces, and how their faces can express numerous and diverse emotions. The brain/body connection informs emotions/thoughts, and so parents experience this rather seamless cyclical response with their children. With child-focused Dialectical Behavior Therapy, we teach children to observe this cycle, the strong influence of his/her face, and teach them where they can intervene or slow their emotional reaction, simply by using mindfulness techniques regularly practiced in the session.

We teach the child to notice things such as muscle contraction/relaxation, heart rate, temperature changes, breathing quality, dilation/contraction of blood vessels (flushed fact) and evidence of perspiration. We show them how their own bodies are senders and receivers of emotions, and empower them to take control, first  through observation, and then with actions. With child appropriate exercises, we teach the child about fight/flight, and provide these exercises to the child’s parent for additional practice at home.

 Thoughts and Emotions have their own unique topography (see Marra, 2004). The child’s caregivers begin quite early in providing the child with interpretations, judgments, analyses, and also teach them what to worry about, and what to ignore. Thoughts are obviously manifested from the child’s observation of his/her caregivers, but they also come from what the caregivers express directly to the child.  Teaching basic mindfulness skills to the child’s parents is, then, important.

And, of course, with normal development, the child begins to formulate his/her own thoughts. We teach the child to again observe the internal dialogue, without judgment as to the source. We talk often about “self-talk” and distinguish between helpful/unhelpful self-talk. It is important that the child and parent both realize that thoughts are very powerful, not always accurate, and not only define how we feel, but can also create a feeling.

As appropriate for their age, we convey the general belief in DBT that black/white, all or nothing thinking, can lead to trouble with emotion regulation, distress tolerance and interpersonal effectiveness.

Behavior is yet another factor with respect to Emotion Theory. Behavior is both prescriptive and descriptive (see Marra, 2004). The child’s brain watches his/her behaviors. Intervening at the behavioral level with children can be a frustrating for many parents, especially for the parents of emotionally sensitive children. In therapy, we role play a variety of situations to help the child gain insight into the influence of behavior on his/her emotions. Slowly, we integrate “real-life” situations in an attempt to deepen the child’s understanding of her/his emotion-based behaviors. We teach the child how to self-identify his/her needs, and then implement behavioral skills that teach them “accurate expression.”  In this way, we work with the family regarding the concepts of “validation” and “invalidation”.

Human beings are adaptive. Our history and patterns inform our emotional functioning. History can often predict current emotional reactions. With this in mind, we work directly with the child’s family to become mindful of their history and then create new habits and skills. Thus, family intervention is clearly expressed at the outset of treatment. We help the child understand the concept of defensiveness, that is, how they protect themselves from emotional injuries. With understanding of your child’s defense mechanisms, we steadily offer them alternatives to defenses that no longer result in effectiveness or positive results for the child and his family/parents/educators. Focus on the environment is paramount when teaching a child the life skills highlighted in DBT. In the spirit of social work, systemic interventions often extend beyond the child’s primary caregivers when possible. Without an informed/educated environment, the child may not realize that more positive coping skills actually work.

Children’s DBT, then, can include regular family or multi-family sessions where role-play is emphasized. We present an array of fictional role-plays to solidify the concepts in DBT; Mindfulness, Emotion Regulation, Distress Tolerance and Interpersonal Effectiveness.

For information about the Child/Family DBT Program, please contact Patrick at 303.909.9054.  Child/Family DBT is specifically for children ages 7-12. For ages 13-17, we recommend the program which is operated through Denver DBT. Cherry Creek Psychotherapy, LLC also offers a young adult depression and anxiety group for ages 18-26. This young adult group is heavily focused on DBT skills as well. 

Patrick Cole, LCSW and Cherry Creek Psychotherapy will offer an informational presentation on the effectiveness of DBT for adolescents/adults struggling with anger, anxiety, emotion dysregulation, mood instability or suicidal/self-harming behaviors. This will be offered to the public at no cost on Saturday, June 18th, 2011 at noon at the offices of Denver DBT, 1660 South Albion Street, second floor conference room.

This presentation is for adults/parents of teens, or significant others of people who are either currently in a DBT group, or have completed one recently. We will discuss how to differentiate between typical teen struggles and the diagnosis of Borderline Personality Disorder, as well as regressed personality structure in adults. We will have a question and answer session following the presentation at 2PM.

Please RSVP to 303.909.9054.

I have experienced a recent increase in calls from people inquiring about doing individual DBT versus Group DBT. Here are some pros and cons to help you with your decision.

When Marsha Linehan developed Dialectical Behavior Therapy, the research found that this particular type of treatment was more effective in a smaller group setting, when coupled with individual psychotherapy. The benefits of numerous perspectives, peer support, peer empathy and general group structure, should all be considered. Members are also accountable to not only the group leaders, but also the other members. There is also a nice shared-experience and empathic element in  a group.

In a group setting, there are typically two co-leaders. Having two qualified clinicians in the room offers members a more balanced overall experience. While one leader is teaching the skills, the other leader can monitor the  group for nuances not recognized by the one focused on material. Lastly, group DBT is often less costly than individual DBT.

Group DBT, though, can be a significant time commitment. It can take as long as one year to get through all four DBT modules, depending on the size of the group. It can be frustrating for someone who picks up the skills quickly, but must wait while others struggle, or fail to practice the skills, thereby effecting the flow of the group in a challenging way. True, it is the leader’s job to keep the group moving along smoothly and effectively while addressing all of the glitches that arise in any group setting. But, it’s not always so easy.

For those who wish to learn DBT skills, but experience difficulty with the overall time commitment, there is always the option of doing individual DBT. The benefits of individual DBT are as follows. First, it is certainly possible to work through all four modules in less than 6 months. Next, while it is important to cover the skills exactly as they are outlined by Marsha Linehan in her skills training manual and seminars, individual DBT can be tailored to the individual’s situation. In short, we can go into each skill in detailed fashion; no delays or other individuals asking questions or creating problems. We can also spend more time on specific situations, applying the appropriate skill, and the contemplating it’s effectiveness. So, individual DBT can be more detailed, efficient and effective, in terms of really understanding and incorporating the skills. There is obviously more time to discuss each skill; more time for contemplation, debate and questions. Really, there is more focus on you and your specific challenges.

Individual DBT, though, has it’s drawbacks as well. If the therapist is not careful, a drift can arise in the sessions. That is, DBT can often get sidetracked, slipping into process rather than education of coping skills. Maintaining a certain structure is paramount. Also, individual DBT is usually a bit more costly than DBT in the group setting. And lastly, group DBT offers a wider support network; more people to reach out to during times of increased stress. With individual DBT, there is only the DBT therapist.

There are certainly numerous other reasons why people choose one format over the other, and I always discuss those with potential DBT clients. We discuss, in detail, the motivations/reasons for wanting to do one format over the other, to ensure that it is the right, and clinically appropriate, format for the prospective client. In the end, the most important thing, in either setting, is willingness. The format really makes no difference at all, so long as it’s the format helps the client maintain a willingness to consistently practice the skills that work!

Happy Spring!

Patrick.