This feature by Francheska Perepletchikova, PhD is Part 3 of 3 in a series about understanding DBT-C, presented in a question and answer format. In the first part, we defined DBT-C, addressed the target population and the most frequent diagnosis, and examined how symptoms may differ from other disorders. In the second part, we explored how emotional dysregulation develops, what kind of parenting is needed, and the main goals and primary treatment targets of DBT-C. Now, we wrap up with part 3, in which Francheska gives an example of how DBT-C hierarchy is applied during a session, as well as an example of a child-friendly modification to standard model DBT. She will also talk more about therapy-interfering behaviors, secondary treatment targets, and the main mechanists of change.
Question: Can you give an example on how DBT-C hierarchy is applied during a session?
Francheska: Let’s say a family wants to discuss a problematic incident where the child used verbal aggression (which included threatening, swearing, name calling and malign comments). Regardless of how severe, inappropriate or disrespectful were the child’s verbalizations, parental behaviors before, during and after the incident would be prioritized. As per the hierarchy, parental responses take precedence over the child’s behavior. If a parent was modeling effective behaviors (i.e., remained calm, validated, used emotion regulation skills, generated effective solutions, ignored), even if a child had a meltdown for two hours, the situation was effectively resolved. In this case, the environment was no longer transacting with a child in a dysfunctional way. If applied consistently, parental adaptive responding over time may result in the creation of a validating environment, and the resulting transaction may help ameliorate the child’s emotional and behavioral dysregulation. Conversely, in a situation when a child responded effectively to a stressor (e.g., used coping skills, walked away to prevent escalation), while parental responses were dysfunctional (e.g., resorted to screaming or threatening), the incident was not effectively resolved. Without environmental support, the observed child’s adaptive behaviors are likely to remain isolated and sporadic incidents.
Question: Therapy interfering behaviors of a child are last on the hierarchy. This is in contrast to the standard model DBT where therapy-interfering behaviors of a client are at the top of the hierarchy. Can you please explain?
Francheska: DBT-C is quite tolerant of a child’s behaviors that may interfere with treatment. This stems from its ability to rely almost exclusively on parental learning, when necessary, which significantly relieves the pressure of ensuring the child’s full engagement in therapy. In DBT-C, a child’s problematic behaviors during a session (cursing, screaming, using threatening body language, devaluing treatment as a waste of time, running around) are just ignored with a plan to help a child re-regulate and re-focus attention when appropriate. If such behaviors occur consistently, they are targeted by a shaping program.
Further, temper tantrums during sessions are informative and target-relevant. They allow a therapist to: 1) observe parent-child interactions; 2) model to parents how to respond to problematic situations; 3) coach parental responses in the moment; and 4) model effective conflict resolution, problem-solving and skills-use to parents and a child. Ignoring of problem behaviors in session also helps with extinction generalization (e.g., swearing is not attended to at home and in therapy). Attempts to correct therapy-interfering behaviors as they are occurring during a session via discussion, behavior analysis, or punishment can reinforce these behaviors with attention, interfere with addressing higher level targets (e.g., teaching skills to parents), lead to escalation, strain the therapist-child relationship, and decrease a child’s willingness to attend further sessions.
Question: What are the secondary treatment targets of DBT-C?
Francheska: DBT-C aims at helping parents instill in their children three core senses: self-love, safety and belonging.
Sense of self-love refers to a stable and enduring sense of love for self as is, without conditions or requirements. It allows a person to appreciate and enjoy one’s own abilities, inborn aptitudes, talents and inclinations, as well as acquired facilities, interests, competencies, expertise and mastery. It also allows a person to accept self as imperfect when the environment imposes standards. Parental love for the child provides a foundation for the child’s ability to experience self-love. Pervasive and indiscriminate invalidation interferes with the child’s ability to experience self-love. It is hard for the child to feel love toward herself if she believes that she is not even good enough to garner the love of her own parents.
Sense of safety refers to a realistic appraisal of dangers and one’s own ability to handle problems. Sense of safety starts to develop within a secure environment, where caregivers provide stability, protection and consistent support. Sense of safety continues to develop when a child acquires better control over her own responses and accumulates life experiences to trust that she is able to effectively deal with life challenges. The sense of safety may not properly develop when an environment is unpredictable and sometimes responds effectively to the child’s needs and sometimes does not, pervasively invalidates the child’s abilities to handle internal and external events and frequently accommodates maladaptive responses. Failure of the environment to provide consistent protection and support interferes with the child’s ability to trust self, others and the world.
Sense of belonging refers to an enduring sense of being welcomed and accepted as a part of a group. Sense of belonging starts to develop within a family through a positive relationship with caregivers that provide a consistent message that the child is accepted. A relationship where parents frequently use downward comparisons and are critical, judgmental, retaliatory, invalidating, punishing and dismissive is likely to communicate messages to the child that she is not good enough, “defective,” different, not accepted and even not wanted.
In DBT-C, a therapist uses Core Problem Analysis, an assessment and intervention model, to evaluate vulnerabilities in the core senses and to target them using specific techniques and via helping parents create a validating and change-ready environment.
Question: Can you give an example of a child-friendly modification to standard model DBT?
Francheska: In DBT-C concepts are simplified to promote better comprehension, given the developmental level of the target population. For example, DBT-C introduced Emotion Change Model that discusses emotion regulation as ‘not feeding’ an unwanted emotion. Children are taught that emotions have three main sources of food: 1) doing what an emotion is saying to do (i.e., following an action urge); 2) thinking what an emotion is saying to think (e.g., rumination about a triggering event); and 3) maintaining tension in the body that is associated with emotional arousal. So, to change or stop an emotion, all three sources of “food” have to be interrupted. Emotion regulation skills, such as ‘Surfing Your Emotion’ and ‘Opposite All the Way,’ can change an emotional experience because they include techniques that interrupt all three sources of ‘food’ for an emotion.
For example, the ‘Surfing Your Emotion’ skill 1) interrupts action by engaging in a skill instead of a dysfunctional behavior, 2) interrupts rumination by re-orienting attention from thoughts to sensations in the body that are associated with an emotion (e.g., ‘butterflies in the stomach’ for fear), and 3) release tension by doing half smile and willing hands. Most of the distress tolerance skills, on the other hand, are designed to tolerate a situation without making it worse and not to change an emotional experience, as they usually interrupt just one or two of the ‘food’ sources (e.g., ‘Do Something Else’ skill interrupts dysfunctional actions, ‘Tense and Release’ skill interrupts a dysfunctional action and releases tension).
Question: What are the main mechanists of change in DBT-C?
Francheska: Mechanisms of change in DBT-C are still to be evaluated by research. However, the model emphasizes three variables; 1) parental emotion regulation; 2) validation; and 3) skills practice. The first two are self-explanatory. Validation is a foundation for change and it is obvious that without emotion regulation, parents will be unable to model adaptive behaviors, validate, reinforce, ignore, and so forth. I would like to discuss skill practice in more detail. As you have probably noticed, I said skill practice, not skills use. Skills use is our goal but not our tool (or mechanism). In order for a change in behavior to occur, there needs to be a significant amount of reinforced practice. How often can we expect a child to use skills, especially at the beginning? Maybe 3-4 times per week. This frequency is simply too low to establish a behavior. Therefore, we rely on skills practice.
Skills can be practiced with children in four main ways, such as during: 1) an actual problematic situation; 2) processing of a problematic response after an outburst has occurred and rehearsing alternative solutions; 3) the practice of skills in hypothetical problematic situations via role-plays; and 4) coping ahead of problematic situations that are likely to happen in a near future and deciding on how to respond. Parents are asked to practice skills with their children as often as possible, at least twice per day (if skills are practiced less often, this is addressed as a therapy interfering behavior of a parent).
Question: Can you recommend resources for further reading about DBT-C?
Francheska: Currently I have two books in preparation — a DBT-C treatment manual and DBT-C treatment handouts and worksheets. The materials are not yet available for distribution to general public. However, Behavioral Tech is conducting DBT-C training workshops. Participants are provided with treatment handouts and other pertinent materials. There are also several publications on DBT-C that may be of interest:
Perepletchikova, F. (in press). Dialectical Behavior Therapy for pre-adolescent children: An overview of the model. In, L.A. Dimeff, S. Rizvi, & K. Koerner (Eds), Dialectical Behavior Therapy in Clinical Practice. NY: Guilford Press.
Perepletchikova F (in press). Clinical illustration of the Dialectical Behavior Therapy for pre-adolescent children. In, J. Bedics (Ed,), The Handbook of Dialectical behavior Therapy. Elsevier
Perepletchikova, F. (2018). Dialectical Behavior Therapy for pre-adolescent children. In, M. Swales (Ed.), The Oxford Handbook of Dialectical Behavior Theory (pp. 691-718). UK: Oxford University Press.
Perepletchikova, F., Nathanson, D., Axelrod, S.R., Merrill, C., Walker, A., Grossman, M., Rebeta, J., Scahill, L., Kaufman, J., Flye, B., Mauer, E., & Walkup, J. (2017). Dialectical Behavior Therapy for pre-adolescent children with Disruptive Mood Dysregulation Disorder: Feasibility and primary outcomes. Journal of the American Academy of Child and Adolescent Psychiatry, 56, 832-840.
Perepletchikova, F., & Goodman, G. (2014). Two approaches to treating pre-adolescent children with severe emotional and behavioral problems: Dialectical Behavior Therapy adapted for children and Mentalization-Based Child Therapy. Journal of Psychotherapy Integration, 24, 298-312.
Perepletchikova, F., Axelrod, S., Kaufman, J. Rounsaville, B. J., Douglas-Palumberi, H., & Miller, A. (2011). Adapting Dialectical Behavior Therapy for children: Towards a new research agenda for paediatric suicidal and non-suicidal self-injurious behaviors. Child and Adolescent Mental Health, 16, 116-121.
Interested to read more about DBT? Check out this blog from Dr. Sara Schmidt on “The Role of Emotion Regulation in DBT.”
Francheska Perepletchikova, Ph.D. is a DBT-Linehan Board of Certification Board Certified Clinician and is an Assistant Professor of Psychology at the Department of Psychiatry at Weill Cornell Medical College. Dr. Perepletchikova is a Founding Director of Youth-Dialectical Behavioral Therapy Program, that provides services to children, adolescents and young adults with a range of psychiatric conditions. Dr. Perepletchikova maintains her clinical practice at White Plains, NY. Read her full biography on the Behavioral Tech website here.