This feature by Gloria Seo, LCSW-C and Casey Anderson, LCPC, RPT is Part 1 of 2 in a series about clinical interventions that honor the core concepts of DBT-C. In this first part, Gloria and Casey address their favorite interventions in Pretreatment.
“There’s no way I can be the boss of my big feelings – I’d have to be from the planet Krypton and wear a big “S” on my chest to be that strong.”
– Said by an 8-year-old client during a Dialectical Behavior Therapy for Children (DBT-C) goal-setting session.
Dialectical Behavior Therapy for Pre-Adolescents and Children (DBT-C) is a clinical intervention regularly implemented in our practice.
Developed by Francheska Perepletchikova, PhD, DBT-C retains all the principles of its predecessor, Dialectical Behavior Therapy (DBT), including acceptance, change, and dialectical treatment procedures. However, there are some adaptations that address developmental differences of a pediatric population – our clients are children, after all. Plus, there is an expanded treatment target hierarchy consisting of ten targets. (We’ll write it numerically in case you think you misread that number – yes, 10!) Safety concerns aside, a top priority is parental emotion regulation. Parents have to successfully complete — at minimum — an eight-week training period to develop acceptance-based strategies (validation), behavior modification techniques, and brand-new dialectical dilemmas. But once that’s under wraps, weekly individual psychotherapy commences.
We have detailed some of our favorite interventions that honor core concepts of DBT-C, while balancing children’s interests to increase engagement. The list below details some of core procedural concepts covered in DBT-C individual psychotherapy, including some our favorite experiential interventions to enhance children’s awareness, capabilities, and motivation. Our interventions are often driven by our clients’ personal interests, which might include various games, pop culture references, music, and plain fun. Similarly, metaphors and story-telling are not foreign teaching elements in DBT, and we continue to use them accordingly. Although many of these play-based interventions are utilized with children, we occasionally implement in our comprehensive Dialectical Behavior Therapy for adolescents and families program.
The theoretical underpinnings of DBT are underscored in DBT-C, including the Biosocial Theory. DBT-C practitioners provide a tremendous amount of psychoeducation about emotional sensitivity, emotional reactivity, and slow return to baseline. The flip side of the coin is also discussed, including the extraordinary gifts supersensers possess such as creativity, natural compassion for others, and the propensity for intense positive emotions, too. Dr. Perepletchikova coined the nickname “supersensers” to capture the emotional valence and qualities of these exceptional children. A discussion about the transaction between emotional vulnerability and the invalidating environment also takes place, but in kid-friendly terms.
Unlike DBT for adults and adolescents, DBT-C is unique in that commitment to treatment is obtained from the child’s caregiver. Alternatively, children are invited to make a commitment to treatment, but their express willingness is not required.
However, children are asked to generate a list of their own goals. We often find that these short-term and long-term goals range in topics and ideas. For example, one child’s short-term goal was to decrease physical aggression at school, but the long-term goal was to live in a castle with five cats. In this case, commitment strategies were utilized to help the child learn how using skills to override aggressive action urges could be utilized in the long-term to graduate school, obtain a job, and yes, perhaps even one day live in a storybook castle full of cats.
Didactic Topic: Psychoeducation about the Pros/Cons of Emotional Vulnerability
Playful Intervention: Superhero and Super Power Metaphor
Much like adult-focused DBT, psychoeducation related to emotional vulnerability is provided to children. We have had great success in likening emotional vulnerability to a superhero’s set of powers: When left unchecked, they can leave one in dysregulation and, with mindful, skillful control and practice, they can effectively satisfy goals consistent with Wise Mind values and priorities. Think Spider-Man: “With great power, comes great responsibility.”
Didactic Topic: Psychoeducation about Emotional Reactivity
Playful Intervention: Emotional Reactivity
Emotional reactivity, or the tendency of an individual to experience strong emotional reactions, is discussed during individual psychotherapy. Children (and adults for that matter) often benefit from visual aides that illustrate didactic concepts. A variety of toys can be helpful to complement verbal discussion. For example, a colorful abacus is an excellent way of demonstrating that emotions can come in different strengths and sizes. A toy abacus typically consists of different color beads, with each color representing an emotion. Clinicians can help demonstrate that the more beads present, the stronger the emotional responses. One of our favorite interventions — a Hoberman sphere — is also useful. The clinician can demonstrate how emotional responses can grow rapidly and strongly, based off the controllable size of the sphere.
Clinical Topic: Goal-Setting
Playful Intervention: Pokémon Evolution Metaphor
In case you didn’t know, Pokémon are fictional video game creatures that nearly dominate the world of video game pop culture. Much like a caterpillar undergoes a metamorphosis to become a butterfly, the majority of Pokémon undergo a metamorphosis, fueled by experience and learning, to become more powerful versions. This process is called evolution. For children who are interested in Pokémon (and there are many), it can be helpful to print out pictures of their favorite Pokémon in each iteration of its evolution. Under each iteration, the clinician helps the child list treatment goals related to individual goal setting (e.g. Making more friends at school, spending more time with Mom and Dad, Remembering to bring in my folder to school).
The DBT-C Diary Card
Caregivers help their children keep track of diary card data collection daily. DBT-C diary cards track target behaviors, emotions (and their intensities), and the presence of skills practice. Although DBT-C diary cards can take a standard form, we have found success in encouraging caregivers and their children to design diary cards through use of favorite characters, preferred aesthetics, and words/expressions of encouragement. Indeed, this strategy has served as a pleasant parent-child activity that functions to (1) Increase the child’s motivation by way of reciprocity and (2) Reinforce the child’s willingness and capability as it relates to self-monitoring.
Read here for part 2, in which we will address interventions in individual psychotherapy.
Gloria Seo, LCSW-C is a Licensed Clinical Social Worker (LCSW-C) and a Board-Certified Supervisor in the state of Maryland. She obtained her undergraduate degree from the University of Maryland and her master’s degree in social work from the University of Maryland, Baltimore. Gloria treats a wide variety of mental health issues and has a special interest in challenging and difficult to treat children and adolescents. Read her full bio here.
Casey Anderson, LCPC, RPT received his Combined B.S. in Psychology: Clinical Concentration, Sociology, and Anthropology from Towson University and his M.S. in Clinical Psychology from Loyola University Maryland. Casey has professional experience in various settings including Level V nonpublic educational placements, partial hospitalization treatment, and outpatient mental health clinics. Read his full bio here.