DBT & Personality Disordered Youth Michelle C. Jacobo, Ph.D. Chief Psychologist, Blake 11 Director, Dialectical Behavior Therapy Assistant Professor, Harvard Medical School
Personality Defined Healthy Personality Flexible Adaptable Less mature coping strategies are kept in check Disordered Personality Rigid Maladaptive Immature, primitive coping strategies are prominent Aids in social interactions Disrupts social interactions Source: Blais, Smallwood, Groves & Rivas-Vazquez. Personality and personality disorders. In T. Sterns (Ed.) Handbook of Source: Blais, Smallwood, Groves & Rivas-Vazquez. Personality and personality disorders. In T. Sterns (Ed.) Handbook of Comprehensive Clinical Psychiatry (in press). Comprehensive Clinical Psychiatry (in press).
Should We Diagnose Personality Disorders in Adolescents? Data to suggest that there are enduring characteristics from infancy to adulthood Data to support a fluid developmental process and environmental influence Treat Treat Treat Early intervention may help before maladaptive sxs are solidified Fact or Fiction: Diagnosing borderline personality disorder in adolescents. Clinical Psychology Review 28(2008) 969-981
BPD Criteria Reorganized A disorder of dysregulation: Cognitive Transient paranoia Dissociation Emotional Affective instability Anger Behavioral Impulsive behavior Self-harm Interpersonal Fear of abandonment Intense, unstable relationships Self Chronic emptiness Identity disturbance Source: Linehan (1993)
Psychological Coping Effort we expend to solve personal and interpersonal problems. Effort to master, minimize, or tolerate stress or conflict. We all have coping, sometimes effective, sometimes not so much. Coping style: Problem Solving or Reason Based, Emotion Based, and Integration of both is ideal
Seek the Middle Path Overall construct is healthy is flexible, balanced, doing what the situation calls for, not how we think it should be Have more than one way of relating to reality, a tool box vs just a hammer. Aim for the middle, see balance: experiential avoidance vs flooding Healthy self concept and other concept Mountain self
DBT Overall Coping Approach CBT = change oriented Validation = acceptance oriented Healthy emotion regulation requires both - crucial to teach both
Emotion Regulation: What parents should know and try to model How to regulate emotions and behaviors How to re-orient attention Reduce problem behaviors and increase skills Experience a range of emotions without acting on emotions Improve relationships *How to learn to observe yourself and your teen in the moment, accept where you are nonjudgmentally
Regulating through Behavior All Behavior Has A Function Non-judgmental assessment of behavior and consequence can lead to problem solving which should include Provide clear rules: reward desired behavior, consequences for not following (beware intermittant behavioral reinforcement)
Emotion Regulation: Basic Behavior Paradigm Cue Problem Behavior Consequences
Basic DBT Paradigm Cue Emotion Dysregulation Problem Behavior Consequences
Example of OD Cue Emotion Dysregulation Problem Behavior Consequences Fight with boyfriend Obsessing Urges Emotionally overwhelmed Overdose Overdose = solution = solution Short term: Regulation Short term: Regulation Long term: Dysregulation Long term: Interpersonal Dysregulation chaos Interpersonal chaos
Symptoms are coping-best effort Maladaptive behavior is an attempt to alleviate intense emotion E.g., cutting = immediate physiologic relief Behavioral dyscontrol = increased attention = relief Keep in mind: patient s behavior is problem, not patient
Emotion Regulation: Basic CBT to help you intervene Cognitive Restructuring: adding flexibility Thinking something does not mean it s true. Interpretations of situations can have a strong effect on how you feel. More accurate interpretation leads to improved mood & more effective behavior. Goal is to identify self-defeating thoughts and related emotions: in session & self-monitoring homework
New Strategies Added to Standard CBT Acceptance-based Strategies Mindfulness Particular way of paying attention on purpose, in the present moment & non-judgmentally Participate in life w/ greater moment-by-moment awareness Validation Dialectics Opposites can be integrated to form a closer approximation of the truth Synthesis of acceptance and change
Emotion Regulation: Acceptance Finding a way to accept the current situation and oneself as is This very moment: staying with the breath and finding a way to cope with now (creating a softening of the moment where possible). Anchors us to re-enter the moment: 3 minute breathing Accepting that negative is a part of human experience we think the point is to pass the test or to overcome the problem, but the truth is that things don t really get solved. They come together and they fall apart. Pema Chodron Awake, alive, fully curious, about now
Mindfulness Definition: a particular way of paying attention, on purpose, in the present moment & non-judgmentally. (Kabat-Zinn, ref) Participating in life w/ greater moment-bymoment awareness. Contrasted with mindlessness or automatic pilot Roots within spiritual traditions, but now also in the zeitgeist of popular culture & health Mindfulness practice vs. meditation
Mindfulness teaches parents and teens With practice, helps pts to: Experience feelings without being overwhelmed by them Establish observing distance from emotional experience, introducing space to make more effective choices Psychological Snorkeling Build a more cohesive, benign sense of self.
OBSERVE Mindfulness: DBT What Skills Definition: Sensing and experiencing events, thoughts, emotions, even if they are upsetting Goal: Experience the moment by paying attention and being aware to whatever is happening in the moment What it gets you: Observing things requires you take a step back This gives us distance needed to re-focus and get more expansive perspective on a situation
DESCRIBE Mindfulness: DBT What Skills Definition: Using words to say what you observe Labeling Goal: Learning to gain emotional distance, not take emotions or thoughts literally Thoughts are thoughts, they are not facts What it gets you: Being able to use words to describe behavior and environment Critical for communicating with others and improving self control
PARTICIPATE Mindfulness: DBT What Skills Definition: Goal: Entering completely into whatever you are doing, without feeling selfconscious, distracted, or outside of what you are doing In the moment, participation with awareness What it gets you: Smooth quality of interacting Feeling engaged and in the moment Responding to what reality is, not what we think it should be
Mindfulness: DBT How Skills NON-JUDGMENTAL Definition: Just the facts, taking valence off of experience Goal: To decrease affect, to view universe as it is What it gets you: Acceptance of world Appreciation of moment without authorship of good or bad Improved problem-solving Less fuel for intense feelings
ONE-MINDFUL Mindfulness: DBT How Skills Definition: Doing one thing in the moment Goal: Keep attention focused, not fragmented What it gets you: Fuller moment to moment experience Non-fragmented attention
EFFECTIVE Mindfulness: DBT How Skills Definition: Do what works, what is called for, not what you think it should be Think short term versus long term Goal: To be effective, respond to the situation as it is What it gets you: Less emotional reactions Ability to perceive accurately Smooth connection to the present moment
Mindfulness Exercises Raisin exercise Body Scan Sounds & Thoughts Breath Three-minute Breathing Space plus action step- now in both MBCT and new DBT skills manual. (Video of this one)
Validation To validate is to confirm, to corroborate, to verify, to authenticate, to communicate an understanding (Miller, 2008) Validate the valid Find the kernel anywhere you can Raw material of all the self concept, self reliance, and self regulation
Invalidation To disconfirm, to discount, to delegitamize, to communicate that what the other person is thinking, feeling, or doing does not make sense, is inaccurate, or is an over-reaction
Emotion Regulation:Validation DBT 6 levels: 1. Being present 2. Accurate reflection So I hear you saying I can tell 3. Reading behavior and guessing what they might be feeling. I m guessing from your messages you are very worried 4. Understanding person s behavior in terms of their history. Given your history of chemo the first time
DBT Validation How To 5. Normalizing or recognizing emotional reactions that anyone would have. Of course you are frustrated, we are running an hour behind and you cannot eat until I draw the labs. 6. Radical Genuineness: Treating someone as a real person with real feelings and not a patient. Meeting our patients as an equal Validation reduces affect and increases connection. Allows for assertion via Validate/Assert/Validate
In Treatment or Therapy: Interfering Behaviors Non-collaborative Non-compliance Non-attending Behaviors that interfere with other patients
Emotion Regulation:Use Dialectic Lens More flexible way of thinking More than one thing can be true Allows us to embrace more than one feeling state: allows us to tolerate positions of others. Develop a lens for what is being left out in an emotional moment. Can drop the rope. This and that not This or that
Example of Validate and Limit Set Emotionally dysregulated patient upset at waiting too long and beginning to yell at staff Provide Validation Provide Limit Setting I completely get it. You are pissed and tired and you are just about at the end of your rope, what with how terrible you are feeling in the first place and now this extremely long wait. This is the last thing you needed today AND At the same time you can t yell at staff
Example Continued Plan for going forward: Lets think about where to go from here. It seems the more you yell the more miserable your time is. Have you noticed that? So lets make a plan. First, I will definitely let you know as soon as I hear when you will be seen, and in the meantime let s try and make this more bearable Elicit patient s coping when possible: What helps you get through this time? What things can you do to get your mind off of what upsets you?
Interfering Behaviors of the Therapist or Treater Behaviors that contribute to imbalance: Extreme acceptance or change Extreme flexibility or rigidity Extreme nurturing or withholding Extreme vulnerability or irreverence Disrespectful behavior
Protocol for Treating In-Session Dysfunctional Behaviors 1. Observe the dysfunctional behavior/event 2. Describe the behavior/event as dysfunctional 3. Elicit a coping response or opposite action 4. Instruct the client what to do 5. Orient to importance of new behavior 6. Get commitment to do it 7. Practice new behavior in session 8. Troubleshoot
In Life: possible solutions to distress or problem Solve the problem Change your emotional reaction to the problem Tolerate the problem Stay miserable