incorpora(ng*families*in* adolescent*dbt*to*treat/ preventbpd€¦ · incorpora(ng*families*in*...
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Incorpora(ng Families in Adolescent DBT to Treat/
Prevent BPD Early Iden+fica+on, Preven+on and Treatment of Child and Adolescent
BPD Expert Think Tank, NYC
May 3, 2014
Jill Rathus, PhD Professor of Psychology
Long Island University – CW Post Campus Brookville, New York
And Co-‐Director, Cogni(ve Behavioral Associates
Great Neck, NY USA
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Outline • Biosocial Theory of BPD/Chronic Emo+onal Dysregula+on • Ra+onale for Including Family Members in Treatment • Adapta+ons of DBT for Adolescents Involving Family Members • How including family members can help treat/prevent BPD • Future direc+ons
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Biosocial Theory of BPD (Linehan, 1993)
Jill Rathus, 2012 Do Not Use Materials Without WriXen Permission
Pervasive Emo+on Dysregula+on
Biological Dysfunc+on in the Emo+on Regula+on System
Invalida+ng Environment
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Emo+on Vulnerability (Neurobiological differences)
• High sensi+vity – Immediate reac+ons – Low threshold for emo+onal reac+on
• High reac+vity – Extreme reac+ons – High arousal dysregulates cogni+ve processing
• Slow return to baseline – Long-‐las+ng reac+ons – Contributes to high sensi+vity to next emo+onal s+mulus
Jill Rathus, 2012 Do Not Use Materials Without WriXen Permission
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Characteris+cs of an Invalida+ng Environment
1. INDISCRIMINATELY REJECTS communication of private experiences and self-‐generated behaviors
E.g,. Teen upset about failing test….. “It’s your fault. If you studied more you would have passed.”
OR “Stop worrying, it’s not a big deal; it’s only 1 test.”
2. IGNORES or PUNISHES lower level emotional displays and INTERMITTENTLY REINFORCES emotional escalation “You’re over-‐reacting – being ridiculous…it’s not that big a deal!” Crying escalates—threat-‐I’m not going back to school. “OK, let’s go out for a nice dinner tonight so you’ll feel better and
I’ll help you study next time.”
3. OVER-‐SIMPLIFIES ease of problem solving and meeting goals. “Just study more next time and you’ll do great.”
Jill Rathus, 2012 Do Not Use Materials Without WriXen Permission
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Invalida+ng Environment Teaches Individual to:
1. Ac+vely self invalidate and search social environment cues on how to respond
2. Oscillate between emo+onal inhibi+on and extreme emo+onal styles
3. Form unrealis+c goals and expecta+ons
Jill Rathus, 2012 Do Not Use Materials Without WriXen Permission
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BPD results from transac+on of biological vulnerability with invalida+on
over +me
A1 B1 A2 B2 Ai BPD
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Why Include Family Members?
• Dialec+cal approach holis+c, contextual • Skills acquisi+on for parents, since:
– May be dysregulated, overwhelmed – May not be interpersonally effec+ve – May be inconsistent or extreme in paren+ng
• Intervenes directly: invalida+ng environment • Parents must be engaged to bring teens, follow through, help teens
solve problems • Models for more effec+ve skill use? • Helps with skills generaliza+on • Helps structure the environment: more reinforcing of effec+ve
behaviors • Exposure for adolescents • Increases parents’ social support
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Family-‐Related Modifica+ons in DBT for Adolescents
Rathus & Miller, 2002, Miller, Rathus & Linehan, 2007 • Involve family members in skills training groups (mul+family group format)
• As-‐needed family sessions • New skills module aimed for adolescents and their caregivers (Walking the Middle Path) – Dialec+cs, Dialec+cal Dilemmas – Valida+on, Behavior Change
• Phone coaching for caregivers
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Excessive Leniency
Forcing Autonomy Normalizing Pathological Behavior
Authoritarian Control
Pathologizing Normative Behavior Fostering Dependence
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The cycle of invalida(on (Fruzee & Shenk, 2008 )
Emotional dysregulation
Difficulties with
accurate self-
expression
Invalidation
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Walking the Middle Path: A new skills module for Families
• Behavior Change – Posi+ve reinforcement – Shaping – Ex+nc+on/ignoring – Effec+ve and judicious use of consequences
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Overall Conclusions regarding family-‐based adapta+on of DBT (based on quasi-‐experimental and
ini+al RCT data)
• DBT is a promising treatment for teens with BPD, suicidality, depression, mood, and other behavioral disorders
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Mul+-‐Family Skills Training Group Format
DBT for Adolescents: The Skills
(Adapted from Goldstein, 2012, November)
Core Mindfulness
Distress Tolerance
Emotion Regulation
Interpersonal Effectiveness
Walking the Middle Path
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Acceptability of Walking the Middle Path (Rathus, Miller, Campbell and Smith, under revision,
Amer. J. of Psychotherapy)
• Results: High acceptability of the module, to teens & parents.
• Middle Path skills ranked highly among DBT skills perceived most helpful.
• The Middle Path skill Valida+on was considered most beneficial skill among all DBT skills, with reinforcement close behind.
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How including caregivers in DBT treatment can treat/prevent BPD
• Increases caregiver valida+on & decreases invalida+on
– As such, can increase teen’s emo+on iden+fica+on, emo+on regula+on, emo+on expression, self-‐regula+on and iden+ty, and problem solving
• Increases interpersonal effec+veness & decreases interpersonal conflict and anger
• Increases effec+ve con+ngency management/paren+ng strategies
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How including caregivers in DBT treatment can treat/prevent BPD
• Treats the invalida+ng environment – a causal mechanism • Treats parents -‐ Parents acquire DBT skills; reduces teen sx through social learning, increased effec+ve communica+on, increased authorita+ve paren+ng (which leads to increased self-‐regula+on)
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How including caregivers in DBT treatment
can treat/prevent BPD
• Treats the learning context – targets familial antecedants and consequences of BPD behaviors (e.g. suicidal behaviors, NSSI, impusive behaviors, ineffec+ve emo+on displays)
• Biosocial Theory educates parents – re: emo+onal vulnerability and dysregula+on – allows for effec+ve responses (e.g., seeing suffering rather than “drama” or “manipula+on”) – Different aetude + effec+ve responses decreases emo+onal and behavioral escala+ons
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Conclusions
• Research needed to determine: – Does including Middle Path module and other parent tx modes improve outcomes?
– Does including caregivers in treatment enhance outcomes in youth with BPD?
– Can including caregivers in treatment prevent development of BPD in youth at risk?