1. Running Head: EFFECT OF DIALECTICAL BEHAVIOR 1
Effect of Dialectical Behavioral Therapy on Adolescents
Jehlad Hickson
Stonehill College, 320 Washington Street, Easton, Massachusetts, 02357,
Shield’s Science Center Room 140
PSY 207
Professor Erin O’Hea

2. Effect of Dialectical Behavioral Therapy on Adolescents 2
Abstract
Sarah was an 18 year old female who had been experiencing problems with friends,
family since she was 15. She would often act out impulsively and these behaviors would lead her
to a pattern of unstable and intense interpersonal relationships, characterized by alternating
between extremes of idealization and devaluation. Sarah also had an identity disturbance, which
was a persistently unstable self-image or sense of self. She also exhibited recurrent suicidal
behavior, along with gestures, threats, and self-mutilating behavior. Individuals with borderline
personality disorder show a “pervasive pattern of instability of interpersonal relationships, self-
image, and affects and marked impulsivity that begins by early adulthood and is presented in a
variety of contexts”. These individuals are sensitive to environmental circumstances.
They experience intense “abandonment fears and inappropriate anger even when faced
with a realistic time-limited separation” or when there are unavoidable change plans. Dialectical
behavior therapy is the first “empirically validated treatment for chronically suicidal patients
diagnosed with borderline personality disorder”. Dialectical behavioral therapy is a promising
treatment for adolescents with “BPD sympotomatology, suicidal ideation and comorbid
depression, bipolar disorder, disordered eating behaviors and aggressive and impulsive
behaviors”. Adolescents in these studies were also hospitalized less frequently when treated with
dialectical behavioral therapy. DBT is the first validated treatment for “chronically suicidal
patients diagnosed with borderline personality disorder”.

3. Effect of Dialectical Behavioral Therapy on Adolescents 3
Patient Information/Patient Background
Sarah is a single, white 18 year old female that has been experiencing personal problems
with friends and family. She has found many ways to harm herself, which included overdoses of
medication and cutting herself. Since the age of 15, Sarah would often act out, yelling at her
parents and teachers. She would also make impulsive behaviors, like having sex with boys she
barely knew, and smoking pot and cigarettes in the bathroom. Sarah would form new
friendships, where she would idealize other girls and say that they were her best friends, even
though she only knew the girls for a very short time. Her romantic relationships usually began
and ended the same way as her friendships, which was very abruptly. She would complain about
how alone and bored she felt, how no one would understand her, and how she felt empty.
Sarah started experiencing emotional instability, and her mood changes were
unpredictable. She would have fights with her parents, but at times she seemed terrified to be
without her mother. She would often leave the house in a fit of intense rage and not return for a
few days. Sarah tried to commit suicide by taking an overdose of medications and her mother
found her passed out on the floor. Sarah’s mother also started noticing scars on Sarah’s arms.
Sarah said she felt numb, but when she cut herself she could actually feel something and it
helped relieve her. Sarah also reports never being able to stick to anything in her life. Sarah also
states that her mother would fluctuate between being really helpful and sweet to Sarah and then
becoming angry and neglectful. She doesn’t live with her Dad, but he does live a few hours away
from Sarah and her mother. A psychiatrist who diagnosed her with bipolar disorder and
prescribed a mood stabilizing medication was seeing Sarah for a while but the medicine did not
work.

4. Effect of Dialectical Behavioral Therapy on Adolescents 4
Patient’s Symptoms
Sarah exhibits behaviors of Borderline Personality Disorder. The main feature of this
disorder is a “pervasive pattern of instability of relationships, self-image, and impulsive behavior
that starts in early adulthood”. People with BPD are very sensitive to environmental factors that
play a role in that person’s life. These symptoms are present in a variety of contexts. One factor
that was noticed was a “pattern of unstable and intense interpersonal relationships characterized
by alternating between extremes of idealization and devaluation”. In psychoanalytic theory,
when an individual is unable to integrate difficult feelings, “specific defenses are mobilized to
overcome what the individual perceives as an unbearable situation”.
The individual is said to be using the defense mechanism idealization: “a mental
mechanism in which the person attributes exaggeratedly positive qualities to the self or others”.
When viewing people as all bad, the individual employs devaluation: “attributing exaggeratedly
negative qualities to the self or others”. Another symptom is an identity disturbance: “a markedly
and persistently unstable self-image or sense of self”. This is then followed by recurrent suicidal
behavior, gestures, threats, or self-mutilating behavior. This leads to an “affective instability due
to a marked reactivity of mood, which could include irritability or anxiety usually lasting a few
hours”.
Also, the patients experience chronic feelings of emptiness, inappropriate and intense
anger and difficulty in controlling their anger. They experience intense abandonment fears and
inappropriate anger even when faced with a realistic time-limited separation. People with
borderline personality disorder may idealize potential caregivers of lovers, demand to spend a lot
of time together, and share the most intimate details early in a relationship. They tend to switch

5. Effect of Dialectical Behavioral Therapy on Adolescents 5
quickly from idealizing other people to “devaluing” them, feeling that the other person does not
care enough, does not give enough support, or is not “there” enough. These people are also prone
to sudden and dramatic shifts in their view of others. Such shifts often reflect disillusionment
with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment
is expected.
There are sudden and dramatic shifts in self-image, characterized by shifting goals,
values and vocational aspirations. There may be sudden changes in opinions and plans about
career, sexual identity, values and types of friends. These individuals may suddenly change from
the role of a needy supplicant for help to a righteous avenger of past mistreatment. Although they
usually have a self-image that is based on being bad or evil, individuals with borderline
personality disorder may at times have feelings that they do not exist at all. Such experiences
usually occur in situations in which the individual feels a lack of a meaningful relationship,
nurturing and support. These individuals may show worse performance in unstructured work or
school situations. Sarah had a lot of unstable and intense interpersonal relationship issues with
her friends. She would engage in impulsive behaviors, like having sex with random boys even
though she did not have many friends. Sarah would idealize the other girls, but then turn her
emotions around and have hatred for the same girls that she said were her best friends.

6. Effect of Dialectical Behavioral Therapy on Adolescents 6
Diagnoses
Individuals with borderline personality disorder may have a pattern of “undermining
themselves at the moment a goal is about to be realized”. Examples of this could be dropping out
of school before graduation, regressing severely after a discussion of how well therapy is going,
or destroying a good relationship just when it is clear that the relationship could last. Some
individuals develop psychotic-like symptoms, like hallucinations and body-image distortions
during times of stress. Individuals with this disorder may feel more secure with transitional
objects like a pet than in interpersonal relationships. There are sudden and dramatic shifts in self-
image, characterized by “shifting goal, values, and vocational aspirations”. There may be sudden
changes in opinions and plans about “career, sexual identity, values, and types of friends”.
Experiences usually occur in situations in which the individual feels a lack of a “meaningful
relationship, nurturing, and support”. Individuals with borderline personality disorder may
display affective instability due to “marked reactivity of mood, irritability, or anxiety usually
lasting”. The basic “dyphoric mood” of those with borderline personality disorder is often
disrupted by periods of “anger, panic, or despair and is rarely relieved by periods of well-being
or satisfaction”. These episodes may reflect the individual’s extreme reactivity to interpersonal
stresses. Individuals with BPD may be troubled by chronic feeling of emptiness. Individuals with
this disorder frequently express inappropriate, intense anger or have difficulty controlling their
anger. They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is
often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or
abandoning. Such expressions of anger are often followed by shame and guilt and contribute to
the feeling they have of being evil.

7. Effect of Dialectical Behavioral Therapy on Adolescents 7
ResearchSupported Treatment Recommendations
One behavioral research study that I found was Treatment Preference among Suicidal and
Self-Injuring Women with Borderline Personality Disorder and PTSD. This study examined
treatment preference among suicidal and self-injuring women with borderline and personality
disorder. Women with BPD, PTSD, and recent intentional self-injury were evaluated upon entry
into a psychotherapy outcome study. (Harned et al., 2013). The majority of the women preferred
a combined dialectical behavior therapy (DBT) and prolonged exposure treatment followed by
DBT alone (Harned et al., 2013). Women who preferred the combined treatment were more
likely to report a desire to obtain relief from PTSD and to receive specific DBT and PE treatment
components as reasons underlying this preference. Participants were 42 women with BPD and
PTSD who were accepted into one of two psychotherapy outcome studies. Participants were
excluded of they met the criteria for a psychotic disorder, mental retardation, bipolar disorder, or
were mandated to treatment. Participants were recruited via advertisements and outreach to area
treatment providers. The studies were advertised as a “Dialectical Behavioral Therapy Program
for Suicidal and Self-Injuring Women with Borderline Personality Disorder and PTSD” Harned
et al., 2013). The results stated that the majority of participants preferred to receive a combined
DBT and PE treatment and the remainder preferred to receive DBT alone. No Participants
indicated a preference for PE alone. The present study found that majority of treatment-seeking
suicidal and self-injuring women with BPD and PTSD preferred to receive a combined DBT and
PE treatment over either treatment alone.

8. Effect of Dialectical Behavioral Therapy on Adolescents 8
Another study that I read supporting treatment recommendations was called Treatment
Differences in the Therapeutic Relationship and Introject During a 2-Year Randomized
Controlled Trial of Dialectical Behavior Therapy Versus Nonbehavioral Psychotherapy Experts
for Borderline Personality Disorder. The present study explored the role of the therapeutic
relationship and introject during the course of dialectical behavioral therapy for the treatment of
borderline personality disorder (Atkins, et al, 2011).
Women meeting DSM-IV criteria for borderline personality disorder were “randomized
to receive DBT or community treatment by experts” (Atkins, et al, 2011). The Structural
Analysis of Social Behavior was used to measure both the therapeutic relationship and introject
(Atkins, et al, 2011). The results of this study was that DBT participant reported the development
of a more “positive introject”, including significantly greater self-affirmation, self-love, self-
protection, and less self-attack, during the course of treatment by experts (Atkins, et al, 2011).
The therapeutic relationship did not have an independent effect on intrapsychic or symptomatic
outcome but did interact with treatment.
The third study talks about dialectical behavioral therapy with adolescents. Dialectical
Behavior Therapy (DBT) is a cognitive-behavioral treatment approach with two key
characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies,
and an emphasis on dialectical processes. (Backer et al., 2011). "Dialectical" refers to the issues
involved in treating patients with multiple disorders and to the type of thought processes and
behavioral styles used in the treatment strategies. DBT has five components (Backer et al.,
2011). The first practice is about skill training. The second has to do with individual behavioral
treatment plans. The third is about access to therapist outside clinical setting, homework, and
inclusion of family in treatment. The forth is about structuring of the environment and the fifth

9. Effect of Dialectical Behavioral Therapy on Adolescents 9
emphasizes balancing behavioral change, problem-solving, and emotional regulation with
validation, mindfulness, and acceptance of patients (Backer et al., 2011). Sarah needs to be
treated with dialectical behavior therapy and family based therapy. Emphasis will be more likely
placed on relaxation techniques, like deep breathing and progressive muscle relaxation
techniques, which helps the patient to relax and accept distressing thoughts. Sarah’s emotional
instability would often affect the lives of her parents and herself, but through DBT, positive
reinforcement would help guide Sarah into self motivating herself to get better.

10. Effect of Dialectical Behavioral Therapy on Adolescents 10
References
Atkins, David C., Beldics, Jamie D., Comtois, Katherine A., & Linehan, Marsha M., (2011)
Treatment Differences in the Therapeutic Relationship and Introject During a 2-Year
Randomized Controlled Trial of Dialectical Behavior Therapy Versus Nonbehavioral
Psychotherapy Experts for Borderline Personality Disorder
Backer, Hilmar S., Bosch, Wies van den, Groves, Sameena, Miller, Alec (2011) Review:
Dialectical Behavior Therapy with adolescents
Bohus, M., Haaf, B., Stiglmayr, C., Pohl, U., Bohme, R., & Linehan, M. M. (2000). Evaluation
of inpatient dialectical-behavioral therapy for borderline personality disorder: A
prospective study.
Harned, Melanie S., Tkachuck, Mathew A., & Youngber, Kelly A. (2013). Treatment
Preferences among Suicidal and Self-Injuring Women with Borderline Personality
Disorder and PTSD.
Verheul, R., van den Bosch, L. M., Koeter, M. W., de Ridder, M. A., Stijnen, T., & van den
Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality
disorder
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American
Psychiatric Association, 2013)