This feature by Francheska Perepletchikova, PhD is Part 2 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 this second part, we will explore how emotional dysregulation develops, what kind of parenting is needed, and the main goals and primary treatment targets of DBT-C.
Question: How does emotional dysregulation develop?
Francheska: Emotional dyregulation can stem from a transaction between a child with emotional sensitivity and an invalidating environment. An invalidating environment is not necessarily abusive or neglectful, but rather unable to satisfy the needs of the child.
It is quite a challenge to parent a supersenser. Most parents of supersensers are indeed caring and supportive, and attempt to deal with situations to the best of their ability. They may be quite competent in providing “good-enough” parenting to other children in the family who may not be as emotionally sensitive. However, “good-enough” parenting is simply not good enough for supersensers. The poor fit between the child’s needs and parental capacity to satisfy these needs, may lead to a pervasive transaction where the child’s demands stretch the environment’s resources, and the environment invalidates the child in response. Invalidation dysregulates the child further, resulting in further demands on the environment, and so forth.
This negative transaction increases the risk of these children developing psychopathology in adolescence and adulthood, including personality disorders, depression, anxiety, substance and alcohol use disorders, as well as suicidality and NSSI.
Question: If “good enough” parenting is not good enough for supersensers, what kind of parenting is needed?
Francheska: Supersensers require what can be called super-parents. One of the most important goals of DBT-C is to help parents learn to become super-parents. A super-parent can be compared to a firefighter. Just like a firefighter:
- a super-parent does not start fires (e.g., does not model verbal or physical aggression, does not provoke or invalidate the child, does not retaliate, and does not use prolonged punishment and other ineffective parenting techniques).
- a super-parent is not afraid of fires (e.g., is not scared of the child’s outbursts and does not accommodate the child in an effort to avoid problems).
- a super-parent calmly and skillfully puts out fires and works on preventive measures (e.g., ignores child’s dysfunctional behaviors, validates the child, models skills use, prompts and reinforces adaptive behaviors, uses effective parenting techniques, helps the child cope ahead of problematic situations, maintains the child’s motivation for change, does daily skills practices with the child, develops reciprocity, encourages the child’s self-management and instills in the child a sense of self-love, safety and belonging).
Question: What are the main goals of DBT-C?
Francheska: The main goals of DBT-C are to: 1) teach parents how to create a validating and change ready environment to help them become coaches for their child during treatment and after therapy is completed; 2) teach parents and their children effective coping and problem-solving skills; and 3) help parents instill in their children senses of self-love, safety and belonging. The first two goals comprise primary treatment targets. The third goal comprises secondary treatment targets.
Question: What are the primary treatment targets of DBT-C?
Francheska: In DBT-C the “patient” is not the child but the family and can include siblings, grandparents, babysitters, one-on-one school aids, etc. To incorporate all these variables, the hierarchy of primary targets had to be greatly extended, as compared to DBT for adults and adolescents. While the original DBT hierarchy includes four main categories (decreasing life-threatening behaviors, decreasing therapy-interfering behaviors, decreasing quality-of-life interfering behaviors, and increasing skillful responding), DBT-C has target hierarchy that includes three main categories, divided into ten subcategories:
- Decrease current severe psychopathology and risk of psychopathology in the future
- Decrease life threatening behaviors of the child
- Decrease therapy destroying behaviors of the child
- Decrease therapy interfering behaviors of the parents
- Improve parental emotion regulation
- Teach effective parenting techniques
- Target the parent-child relationship
- Improve the parent-child relationship
- Target the child’s presenting quality-of life and therapy interfering behaviors
- Decrease risky, unsafe, and aggressive behaviors
- Decrease quality-of-life interfering behaviors
- Provide skills training
- Decrease therapy-interfering behavior of a child
As can be seen, most of the subcategories at the top of the hierarchy are targeting parental variables. DBT-C has an inherent advantage over standard model DBT for adults: Ability to target invalidating environment directly and concurrently with the child’s treatment. The main message to parents in DBT-C is that their child’s behavior is irrelevant until parents are able to create a validating and change-ready environment.
For example, the treatment starts in earnest, when a parent says “You cannot imagine how I responded!” instead of complaining to a therapist “Can you imagine what Jonny did?!” This shift signifies that parents have accepted that without their validation, reinforcement, positive modeling and emotional regulation, consistent and lasting changes for the child cannot be expected.
Read here for the third and final part of this blog post, 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. In the final part, Francheska will also talk more about therapy-interfering behaviors, secondary treatment targets, and the main mechanists of change.
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.