Dialectical Behavioral Therapy (DBT)

Case Vignette

Karissa was a tall, athletic 15 year old teenager who was brought into treatment by her mother who had discovered that she was sneaking out at night and using marijuana and alcohol. Further assessment revealed that Karissa was also engaged in self harm, had recently dropped basketball and track (her favorite sports), and was feeling angry and resentful with everyone. “Why don’t they just mind their own business?” Her interpersonal relationships were tumultuous and Karissa would complain that other girls her age hated her and never invited her to spend the night and hang out. She was a straight-A student, but her grades had slipped to a C average over the prior semester. There were also issues that had taken place during Karissa’s early development that were coming into play at the time.

After creating an initial home contract between Karissa and her parents, which placed limits and consequences around her sneaking out and drug use, Karissa began talking about the things she was struggling with. It turned out that six months before entering therapy Karissa had fallen for an older boy at school who was also an athlete. Because Karissa was only 14 at the time they began seeing each other in secret, which continued until the other girl he was dating found out about Karissa and confronted her. Other kids got wind of what had happened and began calling Karissa names and making fun of her at school, which made her feel self-conscious and unable to manage her emotions which seemed completely overwhelming. She was irritable and distant with her old friends and family, and began cutting herself and using drugs and alcohol to dull her emotional pain.

The first core DBT skill that Karissa began working on was mindfulness, which taught her how to stay in the here and now while experiencing all of her emotions in a non-judgmental way. When she became anxious or panicked about a situation or event, such as sitting in one of her classes with another girl who had been mean to her, mindfulness skills encouraged her to fully concentrate on the experience of learning – what was she seeing, hearing, etc. – versus what she was imagining was going to happen when the bell rang. Whenever she felt her anxiety begin to rise she used DBT techniques designed to allow her to acknowledge the validity of her concerns but let go of them so she could remain present.

Additional core DBT skills that Karissa acquired over a six month period included distress tolerance, emotion regulation and interpersonal effectiveness. Distress tolerance taught her how to accept difficult situations in a calm and composed manner so she could make decisions that were thoughtful and effective versus reactive and harmful. She used distress tolerance to help soothe herself when she became worked up and to help her to stay focused on her goals and objectives instead of getting caught up in other people’s drama.

Karissa found the interpersonal effectiveness skills to be particularly helpful. She learned how to say no, ask for what she needed, and deal with conflict in a healthy way. Eventually Karissa and her mother were able to talk to her school counselor about the girls she was having problems with and come up with a plan on how to address the bullying. Karissa was assertive in expressing her needs and able to articulate her feelings and thoughts rationally and mindfully.

Finally, by engaging in the emotion regulation skills, Karissa worked to take more control over the intense feelings she was experiencing instead of letting them get the best of her. This was the most difficult skill set for Karissa to conquer, and she reports that even now, several years later, she still struggles in reducing her vulnerability to their power. But she has also taught herself how to identify feelings before they become a “10,” and learned how to be more mindful of her self-care which meant stopping her drug use, eating regular meals and getting plenty of sleep. Taking care of her personal needs makes her less susceptible to emotional blackmail.

Throughout the course of treatment Karissa also addressed her early developmental history, and how it may have affected her psychological development and ability to engage in relationships. She also had several family sessions where everyone was able to voice concerns and be a part of the healing process. There were many times throughout when Karissa wanted to stop and run away from it all, but she persevered and remains to this day one of the bravest individuals I have had the privilege to work with.

For further information on Dialectical Behavioral Therapy please explore the Behavioral Tech, LLC website.

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