Youth Intervention: Theory, Research, and Practice – Lecture 7 (UNIVERSITY OF AMSTERDAM)

For a personality disorder to be diagnosed in adolescence, the problems have to be present for a year. There are four main areas of deficit:

• Affective dysregulation
• Impulsivity
• Instable relationships
• Identity problems

There are several symptoms of borderline personality disorder (BPD):

• Chronic feelings of emptiness.
• Emotional instability in reaction to-day events (e.g. intense episodic sadness) usually lasting a few hours and only rarely more than a few days.
• Frantic efforts to avoid real or imagined abandonment.
• Identity disturbance with markedly or persistently unstable self-image or sense of self.
• Impulsive behaviour in at least to areas that are self-damaging (e.g. spending; sex; substance abuse; reckless driving; binge eating).
• Inappropriate or intense anger or difficulty controlling anger.
• Pattern of unstable and intense interpersonal relationships characterized by extremes between idealization and devaluation.
• Recurrent suicidal behaviour, gestures, threats or self-harming behaviour.
• Transient, stress-related paranoid ideation or severe dissociative symptoms.

It is essential to assess how severe the symptoms are. The guidelines for personality disorder are treatment using DBT (1), mentalization-based treatment (2) or schema-focused therapy (3). In dialectical behaviour therapy (DBT) there is a constant search for balance between the different theories on which it is based:

1. Cognitive behavioural therapy (CBT)
   This includes analysis (1), problem solving (2), gradual exposure (3), skills training (4), contingency management (5) and cognitive modifications (6).
2. Mindfulness
   This includes learning to stay still (1), learning to have the mind in the now (2), learning to observe without judgement (3), learning to verbalise (4) and radical acceptance of one’s current situation. It has a focus on acceptance and validation of behaviours as it occurs as well as a focus on relationships and interventions on therapy-interfering behaviour.
3. Dialectical theory
   This includes conscious dealing with dialectical dilemmas and the dilemma between change and acceptance. It is about developing a negation as a result of a thesis and an antithesis.

It is an efficacious treatment for BPD as well as for depressed older adults and individuals with eating disorders. It focuses on teaching skills for enhancing emotion regulation (1), distress tolerance (2) and building a life worth living (3).

Dialectical strategies include balancing irreverent and reciprocal communication, as well as acceptance-based and change-based interventions. Reciprocity includes listening and understanding (1), self-disclosure (2) and a sincere warmth (3). Irreverent includes obtaining attention for a subject (1), shifting the affective response (2) and introducing a new perspective (3). Dialectical strategies may be effective through enhanced orienting responses (e.g. by remaining attentive to what is happening, cognitive processing, attention and learning may be influenced) and in vivo learning and modelling.

There are several assumptions of DBT:

• People always try their best.
• People want to improve themselves.
• People must try harder, push more, and be more motivated to change.
• People have not always caused their problems but they need to fix them.
• All behaviour is induced.
• New behaviour skills should be taught in all relevant situation.
• It is important to assess the causes of behaviour and change the behaviour.
• The goal of therapy is to help clients achieve goals they care about.
• It is important to be clear, accurate and compassionate.
• A therapeutic relationship is an equal relationship.
• The behavioural principle applies for clients and therapists.
• The DBT therapist needs support.
• The DBT therapist can make mistakes.
• The therapy can fail.

The biosocial theory of BPD holds that the transaction between a biological tendency toward emotional vulnerability and an invalidation in the rearing environment produces a dysregulation of the patient’s emotional system. Emotional vulnerability includes a predisposition for heightened sensitivity and reactivity to emotionally evocative stimuli and a delayed return to baseline emotional arousal.

The DBT programme consists of four things:

1. Individual psychotherapy (weekly).
2. Skills training in group (weekly).
3. Consultation with team (weekly).
4. Crisis consultation by telephone (24/7).

There are several phases of DBT treatment:

1. Phase 0
   This includes diagnostics and commitment.
2. Phase 1 (i.e. control over behaviour)
   This focuses on control over behaviour and includes treatment of suicidal or life threatening behaviour (1), therapy-interfering behaviour (2), behaviour that conflicts with a life worth living (3) and stabilisation of coping skills (4).
3. Phase 2
   This focuses on experiencing emotion and decreasing posttraumatic stress.
4. Phase 3
   This includes aiming to achieve individual goals and learning to live a life worth living.

During pre-treatment, the commitment to the treatment must be ensured. This tends to vary over time and thus strategies need to be re-used and commitment needs to be renewed. There are several goals of the pre-treatment stage:

• Establish a therapeutic relationship.
• Focus on the specific problems of the patient and link it to areas of dysregulation.
• Link specific problems of the patient to the primary DBT goals.
• Explore long-term goals and link it to reducing problem behaviour.
• Explain that it is not a suicide prevention programme.
• Explain that what the treatment looks like.

Individual psychotherapy always follows the same structure:

1. Mindfulness
2. Daily register of crisis contacts
3. Choice of focus
4. Behavioural analyses (e.g. chain analysis)
5. Solution analyses
6. Practice
7. Exercises and commitment
8. Ending

Mindfulness refers to intentionally directing attention to the present moment experience with an attitude of curiosity and acceptance. It includes focusing on the process of emotion regulation (1), validation (2) and being conscious of the present. The skills can be augmented through training. Mindfulness may be especially useful in adolescence as self-regulation and executive functioning strongly develops during this period.

The effects of MBIs on executive functions are moderated by age. Older adolescents may benefit more from MBIs than younger children due to the window of opportunity (i.e. the period between 14 and 18 years characterized by increases in self-reflection, social-perspective taking and greater interest in the self and others). Having more training in mindfulness is associated with fewer negative behaviours, meaning that the dose of MBI is a moderator. However, younger children have greater improvements than older children or adolescents. The beginner’s mind refers to opening oneself to an experience as if it were the first experience.

DBT makes use of behavioural therapy techniques (e.g. contingency management) and dialectical techniques (e.g. using different perspectives; using metaphors). In DBT, it is important to combine validation, problem-solving and dialectics.There are several aspects in DBT that should be combined and are specific to DBT:

• Validation, problem-solving and dialectics should be combined.
• Consultation should be aimed at the patient.
• The developmental stage of the patient should be kept in mind.
• The systemic environment should be kept in mind.
• There should be a balance between reciprocity and irreverent.

Validation includes explaining behaviour as relevant and meaningful within the context (1), explain the behaviour as logical based on experiences (2) and label the behaviour suited for achieving a specific goal (3). There are several mechanisms of change of validation:

• Increasing the stability of self-views.
• Reducing emotional arousal and enhance learning.
• Increase motivation.
• Modelling and contingency management (e.g. more validation when using a skilful behaviour in session).

The chain analysis is conducted to determine the antecedent events that increased the likelihood that an aversive behaviour would occur (1), the prompting events (2) and the consequences (3). It focuses on moment-to-moment changes in external conditions, emotions, thoughts, behaviours and consequences. There are several potential mechanisms of change:

1. Aversive contingencies
   The chain analysis may function as a punisher for engaging in target behaviour (e.g. patient learns that engaging in these behaviours will lead to a lengthy discussion of the behaviour).
2. Exposure and response prevention
   The focus of the chain analysis is on components of emotion regulation that support or maintain behaviours and discussing this promotes non-reinforced exposure which may make the response less likely and weaken the association between the behaviour and shame (e.g. in the case of self-harm).
3. Enhancing episodic memory
   The detail of chain analysis may enhance episodic memory which is relevant as BPD is characterized by a tendency to have overly generalized memory for personally relevant events.
4. In vivo learning of skilful behaviour
   The dialectical synthesis of assessment and intervention during chain analysis may promote in vivo learning.

Consultation at patient refers to the therapist coaching the patient how to cope with the environment. It may generalize the learned skills to new environments. This has several effects:

• It activates the patient.
• It creates opportunities to learn skills.
• It stimulates self-care and independence.
• It stimulates respect from others for the patient.
• It creates opportunities for validations by meaningful others.
• It counters future problems in a relationship with the therapist or family.
• It prevents conflicting roles for the therapist.

When using environmental interventions in DBT, it is essential to preserve trust between the therapist and the patient (e.g. give general information but not specific about the patient).

Opposite action involves determining that an emotion is unjustified or interferes with behaviour (1), being exposed to emotionally evocative stimuli (2), blocking the behaviour prompted by the emotion’s action urge (3) and substituting a behaviour that is inconsistent with the action tendency compelled by the emotion (4). It aims to target emotion dysregulation and targets a broad range of emotions. There are several potential mechanisms of change:

1. Exposure and response prevention
   This includes exposure to emotionally evocative stimuli while engaging in behaviour that is incompatible with the action tendency prompted by the emotions. Response prevention could occur by demonstrating that the response tendency was unjustified.
2. Broadening the patient’s repertoire and learning of new responses
   It may lead to new response tendencies and actions.
3. Cognitive modification
   It may broaden the patient’s cognitive responses to emotional experiences.

Skills training occurs during the first six months of treatment and consists of weekly, open group sessions of 1.5 hours with 4-6 participants. The goal is to train new behavioural skills in a structured way without distractions of crisis interventions or motivational issues. It trains several things:

1. Attention skills
   This is related to mindfulness and includes being aware of the current moment without judgement and without attachment to the moment.
2. Handling emotion
   This includes improving emotion regulation. It focuses on being able to experience and name emotions (1), target attention away from the things that reinforce emotions (2), regulate physiological arousal (3), reduce inadequate emotion-bound behaviour (4) and regain attention to a non-emotion dependent goal (5).
3. Skills to cope with crisis
   This includes learning a frustration tolerance (i.e. learning to deal with feelings of discomfort without making the situation worse). It consists of learning to endure emotions (1), holding back strong inadequate emotion-dependent behaviour (2) and accepting emotions (3).
4. Handle relationships
   This includes learning complex social skills focused on balanced assertiveness. It focuses on generalizing the social skills to more situations. It holds that the problems are caused by interfering cognitions, emotions and an invalidating environment.

Skills training makes use of a training programme (1), short behavioural and solution analyses (2), role play (3), homework (4) and keeping a journal (5). Consultation by phone allows the patient to call the therapist when crisis behaviour has not occurred yet. The goals are to allow the patient to ask for help effectively (1), provide direct support (2), recover the therapeutic relationship in case of feelings of conflict (3) and bring good news (4).

The consultation with the team includes a weekly meeting by all the therapists. There are several goals:

• Discuss difficulties that therapists experience.
• Share information from skills training.
• Discuss policy and the approach of the institute.
• Discuss problems that therapists experience by implementing the methodology.
• Allow for training in parts of DBT.

In DBT, there are systemic contacts for parents and caregivers and this has several goals:

• Maintain a healthy contact between patients and parents.
• Help parents to offer a stable and safe living environment.
• Help parents to validate the patient and provide support in problem solving.
• Help parents handle conflicts in the family.
• Help parents regain balance in the upbringing.

During DBT, there is evaluation and monitoring of goals and this determines when the treatment is concluded.

For childhood anxiety disorders, CBT is the most effective treatment. As these disorders are strongly related to attention problems (e.g. only focusing on the negative), mindfulness may be beneficial. The main goal of mindfulness-based treatment include helping the child and system recognize triggers for anxiety and identiy skills to use in those situationswhile working to reduce heightened physiological arousal. Anxious children need to regulate anxiety and avoidance independently but they require systemic support and reinforcement.

Mindfulness could also lower the stress in caregivers which allows forbetter parenting, facilitating progress in the child. It also allows the parents to become a model for their child in how to apply mindfulness skills in stressful situations. Self-compassion is an integral part of mindfulness interventions and consists of three components:

• Self kindness
  This refers to treating oneself with care and compassion when experiencing challenges as opposed to self-judgement.
• Sense of common humanity
  This refers to understanding that one’s struggles are part of the human experience as opposed to isolation.
• Mindfulness
  This refers to maintaining a balanced perspective when faced with difficulties as opposed to over-identification.

People who are high on self-criticism may experience fear of compassion (i.e. intense pain that is released because the unconditional love that is practiced reveals the conditions under which one was unloved in the past). Self-compassion may serve as a mediator in mindfulness interventions as it may decrease rumination and emotion suppression and increase positive psychological qualities because self-compassion increases the ability to deal with negative emotions.  In DBT, there are several proposed mechanisms of change of mindfulness:

• Behavioural exposure and learning new responses
  This includes controlling the focus of attention and active learning of alternative responses to stimuli tht elicit unwanted internal experiences. Mindfulness may maintain the extinction of unwanted responses and promotes the acquisition of a new response.
• Emotion regulation
  This includes changing the automatic response tendencies.
• Reducing literal belief in rules
  This includes reducing belief in verbal rules (e.g. “people will laugh at me if I give a speech”) and improving the sense of self.
• Attentional control
  This includes disengaging attention from emotional stimuli.