This feature by Gloria Seo, LCSW-C and Casey Anderson, LCPC, RPT is Part 2 of 2 in a series about clinical interventions that honor the core concepts of DBT-C. In the first part here, Gloria and Casey addressed their favorite interventions in Pretreatment. In part two, they discuss interventions in individual psychotherapy.
Dialectical Behavior Therapy for Pre-Adolescents and Children (DBT-C) is a clinical intervention regularly implemented in our practice. In this part two, we continue to detail some of our favorite interventions that honor core concepts of DBT-C, while balancing children’s interests to increase engagement.
Didactics on Emotions
Affect identification and modulation is the real deal in DBT-C. From the get-go, children are provided with direct education about emotions. What they are, their functions, and the big message: Emotions are a FULL body response. Indeed, children are educated on the behavioral, cognitive, emotional, and physiological components of an emotion. Non-verbal expression of emotion is also discussed, including the role of facial expressions and postures in accurately identifying others’ emotions and expressing their own.
In DBT-C, individual psychotherapy is rich with learning experiences to enhance children’s awareness of emotions. During a typical DBT-C session, children learn how to identify feelings, the cognitive triangle, the functions of emotions, and various myths about emotions. They also learn about the Wave of Emotions, or the sequence wherein a prompting event might start a chain reaction of emotions, action urges, thoughts, eventually leading to target behaviors and their outcomes. Although this is not an exhaustive list of topics and interventions, we have included some to enrich client engagement during a DBT-C individual session:
Didactic Topic: Learning about Emotions
Playful Intervention: Feelings Guess Who
This intervention requires a bit of legwork and is well worth it. The clinician designs different playing cards with various feelings faces. It is helpful to create about ten different cards. Each card is labeled with an emotion, a specific action urge, an example of a cognition, and tension. Just like the classic game, “Guess Who?” the child will issue a series of questions to guess the clinician’s hidden character. For example: “Does your feeling have the action urge ‘to avoid’?”
Didactic Topic: Nonverbal Expression of Emotions via Posture
Playful Intervention: Emotion Charades
A classic intervention, Feelings Charades helps children observe and describe nonverbal communication. The clinician, child, and family members can all take turns acting out various emotions, including specific body language. For example, a clinician can furrow their eyebrows, cross their arms, and start tapping their foot. The DBT-C clinician can encourage children and families to use the describe skill to be nonjudgmental and to deduce the emotion’s nonverbal communication.
Didactic Topic: The Cognitive Triangle
Playful Intervention: Cognitive Triangle Four Corners
Sounds geometrically funky, right? This game allows the practitioner to introduce the cognitive triangle while also playing the classic children’s game “four corners.” In many elementary schools, “Four Corners” is usually a game wherein someone is selected as being “it,” and each corner is designated as “Corner 1, Corner 2, Corner 3, and Corner 4.” The person who is “it” must count to ten with their head down (so as not to see the players), while other players quietly stand in a corner. If the person who is “it” calls their corner, that player is out. The object of the game is to be the last player standing in a corner.
Instead of labeling each corner with a number, the clinician labels each corner with “Prompting Event, Emotion, Thought, and Feeling.” Make sure that you have 4 pieces of paper, markers, and tape to affix to each corner. The clinician can select a benign prompting event, or a prompting event that likely elicits a client’s target behavior. Before playing, the DBT-C clinician discusses how a prompting event can impact the other three corners. For example, the clinician might say “Let’s start with ‘Prompting Event.’ I remember you sharing with me that Dad asking you to do your homework starts to create BIG feelings for you. I wonder how that impacts the other corners?” And then the game can begin. It is also helpful to play this game with family members.
Didactic Topic: Emotion Wave and Behavior Chain Analysis
Playful Intervention: Behavior Chain Analysis – The Floor is Lava
The tradition of behavior chain analysis is not lost in DBT-C. The DBT-C therapist supports children in assessing behavioral targets, prompting events, controlling variables, and their outcomes. For this playful intervention, clinicians require paper and markers (and perhaps some imagination). The game “The Floor is Lava” is a classic children’s game traditionally played in many living rooms around the world (and is now a television show). However, to fuse this game and the tenets of chain analysis together, the clinician communicates to the child that each piece of paper is an element of the chain analysis. In this case, we can refer to an element on the chain as “a boulder.” In order for the child to traverse a given space (like the clinician’s office), they must create their own boulders (paper – with controlling variables such as thoughts, action urges, feelings, cognitions, events) that eventuate to outcomes/consequences (the other side of the clinician’s office). When the child crosses the space, the clinician works to identify outcomes/consequences.
The child must then return to the other side of the room once they reach outcomes. In doing so, the DBT-C clinician can engage the child in solution generation. At each “boulder,” or controlling variable, the clinician can collaboratively introduce skills training, cognitive modification, exposure, and environmental intervention as applicable.
Didactic Topic: Acceptance
Playful Intervention: Finger Trap
The use of a finger trap can be exceptionally helpful in illustrating the role of acceptance. When children are first introduced to a finger trap, they typically act upon the urge to rip their fingers out. However, they quickly learn that forcefully removing their fingers doesn’t work. If they become aggressive, it will likely damage the trap and its ineffective in breaking free. However, children eventually figure out that gently pushing one’s fingers together, loosens the trap, and serves as the path to freedom. This can serve as an excellent metaphor. The DBT-C clinician can then highlight that rejecting the reality of the trap can be ineffective for goals. However, accepting reality for what it is (gently moving one’s fingers forward instead of backwards), can lead to a path of effectiveness.
Didactic Topic: Acceptance and Self-Validation
Playful Intervention: Magic Mirror
For this play-based intervention, the DBT-C clinician will require a mirror and dry erase markers. The clinician explains that acceptance can be helpful in recognizing reality for what it is, including painful emotions, thoughts, action urges, and behaviors. The clinician instructs the client to look into the mirror, and describe emotions, thoughts, and reactions to various stressors or prompting events. In this intervention, the mirror serves as a conduit for reflection, without trying to change anything.
In addition, the clinician discusses the role of self-validation in soothing affect. The DBT-C clinician can then model and coach self-validation in different situations. Once a self-validating statement is created, the clinician or the client can write the state on the mirror. For example: “It makes sense that I would feel hurt when my friend excluded me from her party.”
If you enjoyed this blog, you may also find the blog on The Value of Multimedia in DBT Phone Coaching interesting.
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.