Parents' Guide to Treatment at The Middle Path

This guide was developed to help parent’s navigate your child’s or teen’s individual therapy using the Dialectical Behavioral Therapy (DBT) treatment model at The Middle Path. It addresses some of the common questions that parents have in regards to your child’s treatment and your role in supporting this treatment.

Introduction to DBT Treatment Approach and Bio-Social Theory

Dialectical Behavior Therapy was developed by Dr. Marsha Linehan of the University of Washington in the 1990s as an innovative evidenced-based treatment for clients with Borderline Personality Disorder, which is characterized by difficulties with regulating intense emotion, and the presence of suicidal and/or self-injurious behaviors. DBT has been expanded today to represent the standard-of-care and an effective treatment model to target a wide-range of mental health concerns such as eating disorders, substance abuse, and Post-traumatic Stress Disorder and has been adapted for all ages and populations including adolescents, adults and families.

DBT treatment was developed based on Linehan’s original “Bio-Social Theory”, which posits that many of the difficulties and levels of emotional dysregulation faced by individual with Borderline Personality Disorder and its traits are a result of a transaction between an individual’s sensitive biology and an environment that is experienced as “invalidating.” The “bio”part of the theory discusses that some individuals are born more emotionally sensitive than others. Characteristics of

sensitive biology include heightened sensitivity to emotional stimuli (“small” things might seem to trigger your child when others are not bothered), extreme reactivity (speed and intensity of emotional reactions is high) and a slow return to baseline (it takes a long time for your child to re-regulate). The “social” part of the theory describes characteristics of an “invalidating” environment which include the environment’s rejection of expressions of the individual’s emotions or experiences (“You’re ok! It’s not that big of a deal.”), oversimplification of the ease of problem solving, (“Just put your mind to it and you can get through this.”) and intermittent reinforcement of escalation of emotional displays (sometimesresponding to emotional displays, while other times not). Examples of extreme invalidating envrionmental circumstances can include traumatic experiences, abuse or neglect. The theory suggests that not only does invalidation from the

environment impact and exacerbate emotional sensitivity, but that an individual’s sensitive biology and consequent emotional dysregulation can also shape the environment into becoming more (at times inadvertently, or with the best of intentions) invalidating. An example of this is if your child were to consistently be displaying suicidal or self-injurious behaviors or intense emotional displays, this might shape you or others in your child’s environment to, in the spirit of trying to help or be supportive, send messages such as “It’s ok! Just calm down! It’s not as bad as it seems! Just look at the situation from a more reasonable point of view!” which may be experienced as invalidating to an exquisitely sensitive person. Perhaps in your efforts to encourage, support and cheerlead your child, you receive messages of “You just don’t understand!” which can feel discouraging to you, The transaction between sensitive biology and invalidation from the environment often generates the perfect storm of difficulties you and your child might be currently experiencing. Even if your child does not display life-threatening or self-injurious behaviors, DBT can still be effective in helping your child both accept and change his/her/their own unique emotion regulation style, abilities, and areas of challenge.

DBT Treatment Structure and Order of Target Hierarchy

At its core, DBT is a behavioral treatment. This means that the focus of treatment is on observable, describable behavior, rather than on the idea of unconscious or other un-observable psychological processes, favored by some other treatment orientations. An adherent DBT treatment asks that your child complete a DBT Diary Card, on which they track their urges for and occurrences of “target” behaviors, emotions, and skills use on a daily basis. This diary card is both a self-monitoring

tool that increases your child’s awareness and mindfulness of their own urges, behaviors and emotions and also the crucial framework that structures your child’s weekly DBT individual therapy session. “Target behaviors” are the behaviors that are collaboratively chosen between your child and his/her/their therapist and agreed upon to be “targeted” in therapy. These behaviors are addressed and treated in a specific hierarchy of priority as follows:

“Target I” Behaviors are life-threatening or self-injurious behaviors. These behaviors can include suicidal thoughts, ideations (wishes), behaviors (planning or attempting), and communications (written or verbal statements, threats), or non-suicidal

self-injury such as cutting, burning, or other forms of intentional self-harm without the presence of suicidal intent. If any of these behaviors are present, they are addressed first as the most threatening to DBT’s overall treatment goal of “building a life worth living.”

“Target II” behaviors are known as “therapy-interfering” behaviors. These are any behaviors that interfere with therapy being conducted as agreed-upon and can include behaviors such as missing appointments, late arrivals, non-completion of homework or assigned/recommended therapy tasks, ineffective use of telephone skills coaching, substance use prior to session, or in-session therapy-interfering behaviors such as avoidance of discussing target behaviors or other topics relevant to progress in therapy. If any of these behaviors are present for your child, they will be addressed directly after Target I behaviors, as any behaviors that interfere with therapy make it impossible for therapy to be effective in any other arenas.

“Target III” behaviors are known as “Quality-of-Life-Interfering” Behaviors. These are any behaviors that interfere with the quality of your child’s life. Examples of Target III behaviors are as follows: arguments with others, isolation, avoidance behaviors, substance abuse or disordered eating behaviors (that do not elevate to life-threatening status), unprotected sex, self-judgmental thinking, PTSD symptoms, etc.

“Target IV” behaviors are “DBT Skills”. These behaviors include the acquisition and application of effective DBT skills. DBT skills are acquired by your child through group or individual DBT skills training, and application and integration of skills is reinforced through between-session DBT telephone skills coaching, individual therapy sessions, and/or DBT Skills Integration Group.

The aim of DBT treatment is to decrease Target I, II, and III behaviors, and increase Target IV behaviors.

Behavior Chain Analysis

The Behavior Chain Analysis is a tool used in DBT to examine the triggers and “links”, or steps, that led up to a target behavior. It is also used to assess what factors occurred after the behavior that may be reinforcing the behavior (making it more likely to occur in the future). Following an incident of your child engaging in a target behavior, your child’s therapist may ask him/her/them to complete the behavior chain analysis worksheet and to bring it into the next scheduled session to

review with his/her/their therapist.

Dialectics

The “D” in DBT stands for dialectical. The word dialectical as it applies to our treatment approach refers to a worldview in which absolute truths are disfavored over the notion that multiple truths can exist at once, even if often those truths may seem contradictory to one another or even paradoxical. Those who struggle with emotion dysregulation and/or Borderline Personality Disorder can often become polarized or extreme in their emotions, thinking, beliefs, and/or behavior. This is

also often true for adolescents in general due to their natural developmental stage, as well as for individuals who struggle with other diagnoses such as mood, substance or eating disorders. DBT aims to use a dialectical approach to treatment to help your child achieve “synthesis” or a “middle path” between extremes to achieve a more balanced effective life. The overarching dialectic that is woven into all elements of DBT is that of balancing “acceptance and change”. In our individual

therapy work at the Middle Path, we strive to communicate to and cultivate in your child a simultaneous acceptance of your child as he/she/they is/are while balancing the push for change.

“Consultation to the Patient”, Confidentiality and Direct Communication

The DBT Treatment approach emphasizes several tenets that inform how therapists approach treatment. One of these is “consultation to the patient over environmental intervention.” This tenet guides therapists to consult to their individual clients on how to navigate and manage situations in their lives skillfully, rather than advocating for or facilitating environmental changes on clients’ behalf. As DBT therapists, we believe that an individual client is better served to learn and utilize the tools to navigate a world that will at times be invalidating, difficult, and challenging to his/her/their skill level and capacities, and that changing the world to suit the individual is not only sometimes impossible, but not helpful for your child in the long run. That said, dialectically, there are also times where we may recommend environmental interventions or changes, in particular in cases in which your child does not possess the skill level or ability to manage behaviors that may have life-threatening or otherwise intolerable consequences, or in an instance in which making household or environmental

changes can help shape your child’s behavior towards more effective, desired behaviors. (See

Parent Coaching section below)

It is our experience that children and teens become most effective in their use of individual therapy when they believe that information they share in session is held in confidence from their parents or others. The exceptions to this rule involve suicidal behaviors, or other Target I or life-threatening behaviors such as chronic self-injury, substance abuse, or other behaviors that show a pattern that may be of concern to your child’s therapist. Clinical judgment is used, taking into consideration the age of your child, legal concerns, and other relevant factors. Our first line of action is to use “consultation to the patient” as described above, by encouraging and coaching our individual clients to directly communicate with you, the parent, regarding their target behaviors. In the absence of your child’s willingness to directly communicate with you, and if the therapist’s concern about the risk of the behavior continues, you will be directly informed by the therapist.

We welcome relevant updates or information regarding your child’s progress or behavior in settings where we may not be privy to this information, such as at home or in school. That being said, one of the primary commitments an individual client makes when engaging in DBT is that of honest, direct, and timely reporting of target behaviors on the daily DBT diary card. While this information is for the most part held confidential from you (in the absence of the situations described above), it is an agreement of treatment that your child be reporting instances of target behaviors to his/her/their

therapist directly. Please be aware that information you communicate to us regarding your child’s behavior is as a general rule used directly and transparently in treatment with your child, as “grist for the mill” of effective treatment. We as DBTtherapists are open and transparent about how we received information, and are direct about asking about the presence of target behaviors that your child may not have reported. This absence of accurate reporting from your child may be addressed as a Target II (Therapy-Interfering Behavior) in your child’s treatment.

The relationship between DBT therapist and client is seen as a real relationship, in the sense that the therapeutic relationship may face similar challenges that client may face in relationships in his/her/their life, with friends, family, teachers, peers, or teammates. In this regard, conflicts or difficulties that arise within the therapeutic relationship are addressed directly, transparently, and with the principles of behaviorism in mind (the idea that behaviors increase and decrease based on reinforcement and/or punishment). In this manner, therapist response, praise and the rapport developed in the individual therapy relationship can be used as a reinforcer to increase desired behaviors.

DBT Telephone Skills Coaching

As an individual engaged in DBT treatment, your child has access to his/her/their individual therapist for out-of-session telephone contact for the purposes of DBT skills coaching. The agreements and protocols for skills coaching are discussed and agreed-upon individually between your child and your child’s individual therapist. It is important to note for parents that skills coaching contact is something that is initiated by the individual client (your child), in the event that they are

willing to accept in-the-moment coaching prior to engaging in a target behavior or for help with skills use in general. Therefore, we discourage direct contact from you to your child’s clinician asking for coaching on behalf of your child. We have found through experience that this is often ineffective in “getting” your child to use skills coaching and sometimes “backfires” in the sense that your child may feel angry, embarrassed or like you went “over their head” in contacting the therapist. Furthermore, it is a “lost opportunity” for your child to begin to practice the skill of effectively communicating a request for coaching. Dialectically, we are not opposed to gentle reminders to your child that we are available to your child for skills coaching. A pattern of ineffective or absence of skills coaching use will be taken up in individual therapy as a Target II-“therapy-interfering” behavior.

In general, if your child has already engaged in a target behavior, skills coaching is not to be used, given that your child has already “solved the problem” by engaging in the target behavior. Exceptions to this guideline occur if your child has engaged in a target behavior already but experiences another urge to engage in another target behavior. Your child’s therapist and your child will make agreements together about how to manage a situation like this.

Parent Guidance, Coaching, Skills Training and Family Therapy

There may be times throughout your child’s treatment when parents understandably need and want guidance about parenting decisions, how to manage when their child engages in target behaviors, is having a difficult time or is in crisis, or is not following household expectations and limits. We strongly recommend that you seek the guidance of a skilled DBTtrained

parent coach who can assist you in learning DBT skills, implementing effective parenting strategies that take into account your child’s individual treatment needs, offer on-call parent parent coaching, as well as assist in the development of contingency management plans at home to increase desired behaviors through rewards and reinforcements, and decreased undesired behaviors through punishment if necessary.

In Parent DBT Skills training, parents learn DBT skills from the 4-DBT skills modules: Mindfulness, Emotion Regulation, Distress Tolerance, Interpersonal Effectiveness. Many parents have found that parent DBT skills training can be very helpful not only for parents to apply the skills to their own lives and in parenting their children, but also as a way to familiarize yourself with the same skills that your child is learning in treatment. Having a common language can often be very beneficial. Parent DBT Skills Training can occur individually or in a group setting. Once families and children have developed the skills to effectively manage their own emotions and communicate, family

therapy may be recommended. Family therapy differs from parent coaching/guidance and parent skills training in that it involves the presence of your child, and possibly other children in your family, and is focused on targeting family goals (such as increased validation, communication, and cooperation) rather than parenting behaviors and skills.

At The Middle Path, we offer DBT parent guidance and coaching, parent DBT skills training (individual/two-parent format) and family therapy. Please note that it is recommended that your parent coach or family therapist be a separate clinician from your child’s individual therapist. The rationale for this is as follows:

1) The confidentiality that your child feels

in his/her/their relationship with his/her/their individual therapist is paramount for developing therapeutic rapport and trust that the individual therapist is aiming to work collaboratively towards your child’s stated goals in treatment, making treatment the most effective it can be

2)Your child’s individual therapist will be building an alliance with your child to help

him/her/them skillfully navigate daily life and adhere to any rules/contingencies that you develop and set with your parent coach. That alliance becomes challenged if/when the individual therapist also plays the role of parent coach.

Treatment Planning and Updates for Parents

You will naturally be interested in periodic updates from your child’s individual therapist on your child’s progress in treatment and we are happy to set up treatment update meetings with your child’s individual therapist to review general progress and goals in your child’s treatment, or to plan for new or future directions in your child’s treatment. It is usually recommended that your child be in attendance at these meetings. Your child will be encouraged to make direct reports to you (with help

from the individual therapist if needed) about his/her/their own identified treatment goals, and how your child sees his/her/their own progress in treatment, and to address any questions or agenda items that may be raised during the treatment progress meeting. Your child’s individual therapist can also be available to prepare in advance with your child to be as skillful as possible during these meetings. At times, you may also want to invite your DBT parent coach or family therapist to attend this meeting.

It is our great privilege to be entrusted with the care and treatment of your child. We hope that this guide helps you understand the treatment philosophy that guides our work in DBT at The Middle Path. We look forward to collaborating to help your child to build a life worth living and to navigate it as skillfully as possible.