A UNIQUE APPROACH TO CHILD DEVELOPMENT and FAMILY COUNSELING

HOW OUR MISSION and CORE VALUES became a Therapeutic MODEL

WHAT IS DIALECTIC BEHAVIORAL THERAPY?

Dialectic Behavior Therapy (DBT) is a set of tools to help people recognize and manage their own problems.

The term 'dialectical' comes from the field of philosophy. It is a method of logic and reasoning.

The root “dia” in the word dialectic means two. Dialectic behavioral therapy helps clients manage their lives when two seemingly contradictory realities coexist.

DBT was originally developed by Dr. Marcia Linehan of the University of Washington to work with suicidal and para-suicidal clients with a diagnosis of Borderline Personality Disorder. The therapeutic model has been effective in treatments of a variety of problems that afflict the population that we serve at the Ranch, addiction, eating disorders, and common cognitive dysfunctions of juveniles in foster care or the justice system. It is also effective as a youth development model, in that it provides a tool set useful in managing interpersonal conflicts and stressors likely to arise during the teenage years.

Much of what we teach clients in skills development may seem like common sense advice you would get from a “father-knows-best” or “leave-it-to-beaver” type mentor on managing difficult moments and emotional triggers, if those fictitious characters of 50s TV sitcom fame ever dealt with how to overcome thoughts of suicide, or cope with life after experiences of rape, incest, domestic violence, child abuse, methamphetamine or cocaine addiction, alcoholism or mental illness.

The dialectical approach to understanding and treatment of human problems is non-dogmatic, open and oriented to present self and interpersonal exchange. It is a mentoring process, similar to classic child/parent interaction and involves acquisition of concrete skills.

Success is dependant on the quality of the relationship between the student and teacher or client and counselor. The emphasis is on this being a real human relationship in which both members matter and in which the needs of both have to be considered. The approach is a team approach.

Our methods differ from the classic Linehan model, in that we’ve adapted our model to meet the needs of the teens and adults we are most likely to encounter, and the times, places and ways that we interact with them.

The structure of individual therapy and some of the strategies used for classic therapy are described for introductory purposes only and to assist the counselor in acquiring a full working knowledge of DBT. Most of the work we do is significantly more casual than the one-on-one therapeutic sessions that are primary to the original form of DBT developed by Linehan. Our individual therapeutic encounters are most likely to occur outside the counselor’s office, and in direct response to a present moment experience. Our teaching moment comes in helping a client or student to overcome an immediate crisis. Still, the same premise applies in that the students, clients and counselors need to acquire the working vocabulary and skills training in advance of the actual work and the counselor must understand the nature of how DBT operates in order to be effective in the moment.

The counselor is asked to accept a number of working assumptions that will establish the required attitude for success:

1. The student wants change in her life and a good resolution to the problem, in spite of appearances, is trying her best at any particular time.
2. The student’s behavior pattern is understandable given her background and present circumstances. Her life may currently be chaotic and stressful or the conditions of her life dire. The solution is not to pretend that life is different or to give into feelings of despair but rather to make life worth living.
3. In spite of this, the student needs to try harder if things are ever to improve. She may not be entirely to blame for the way things are but it is her personal responsibility to make them different.
4. The student can not fail in DBT. If things are not improving it is the method of management that is failing.

DBT involves acquisition of a skill set for managing people and situations that many at-risk teens lack. Although these teens, like clients diagnosed with BPD, are often described as "manipulative" – and this implies that they are skilled at managing other people - it is precisely the opposite that is true. The awkwardness and inability to manage conflicts in ideas, people and situations results in the others feeling manipulated to reach a resolution instead of that knowing their ideas are recognized, valued and understood and that the student is synthesizing them.

Other similarities between DBT and good parenting are that the counselor interacts with the client in a way that is:

1. Accepting of the client as she is but which encourages change.
2. Centered and firm yet flexible when the circumstances require it.
3. Nurturing but benevolently demanding.

DBT depends on its success on having the co-operation of the client from the start; therefore, attention is given to orienting the client to the nature of DBT and obtaining a commitment to undertake the work.

SKILLS TRAINING is usually carried out in a group context, ideally by someone other that the individual counselor. At the Ranch, these skills training groups are mandatory for all teen members of the Ranch, for counseling staff and for volunteers who work consistently with clients. Ongoing counseling consultations continue for staff following the initial skills training.

In the skills training groups, clients are taught skills considered relevant to the particular problems experienced by people with borderline personality disorder. There are four modules focusing in turn on four groups of skills:

1. Core mindfulness skills.
2. Interpersonal effectiveness skills.
3. Emotion modulation skills.
4. Distress tolerance skills.

The 'core mindfulness skills' are derived from certain techniques of Buddhist meditation, although they are essentially psychological techniques and no religious allegiance is involved in their application. Essentially they are techniques to enable one to become more clearly aware of the contents of experience and to develop the ability to stay with that experience in the present moment.

The 'interpersonal effectiveness skills' which are taught focus on effective ways of achieving one's objectives with other people: to ask for what one wants effectively, to say no and have it taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people.

'Emotion modulation skills' are ways of changing distressing emotional states and 'distress tolerance skills' include techniques for putting up with these emotional states if they can not be changed for the time being.

Counselors receive DBT from each other at the regular COUNSELOR CONSULTATION GROUPS and, as already mentioned, this is regarded as an essential aspect of therapy. The members of the group are required to keep each other in the DBT mode and (among other things) are required to give a formal undertaking to remain dialectical in their interaction with each other, to avoid any pejorative descriptions of client or counselor behavior, to respect counselors' individual limits and generally are expected to treat each other at least as well as they treat their clients. Part of the session may be used for ongoing training purposes.

In classical treatment modules utilizing DBT, the individual counselor is the primary counselor. The main work of therapy is carried out in the INDIVIDUAL THERAPY sessions. Between sessions in a classic DBT module, the client is offered TELEPHONE CONTACT with the counselor. That contact is not for the purpose of psychotherapy. Rather it is to give the client help and support in applying the skills that she is learning to her real life situation between sessions and to help her find ways of avoiding self-injury. At GATEWAYS, the function of this contact is transferred to the interaction that occurs between the counseling staff and the client on a daily or weekly basis.

Because DBT works best when there is a genuine relationship between counselor and client, the on-going contact is a necessary adjunct to therapy. It provides the client support and also serves the purpose of relationship repair where the client feels that she has damaged her relationship with her counselor and wants to put this right before the next session.

STAGES OF THERAPY AND TREATMENT TARGETS

Clients who present multiple problems can pose problems for the counselor in deciding what to focus on and when. This problem is directly addressed in DBT. The course of therapy over time is organized into a number of stages and structured in terms of hierarchies of targets at each stage. While we do not necessarily provide a treatment assessment for each young person who uses DBT techniques after participating in skills training, when clinical assessment is deemed necessary, the stages of treatment may be referenced as a means of understanding a client’s needs.

The PRE-TREATMENT STAGE focuses on assessment, commitment and orientation to therapy.

STAGE 1 focuses on suicidal behaviors, therapy interfering behaviors and behaviors that interfere with the quality of life, together with developing the necessary skills to resolve these problems.

STAGE 2 deals with post-traumatic stress related problems (PTSD)

STAGE 3 focuses on self-esteem and individual treatment goals.

The targeted behaviors of each stage are brought under control before moving on to the next phase. In particular post-traumatic stress related problems such as those related to childhood sexual abuse and in a DBT module they are not dealt with directly until stage 1 has been successfully completed. Problems of this type (flashbacks for instance) emerging while the client is still in stages 1 or 2 are dealt with using 'distress tolerance' techniques. The treatment of PTSD in stage 2 involves exposure to memories of the past trauma.

Therapy at each stage is focused on the specific targets for that stage which are arranged in a definite hierarchy of relative importance. The hierarchy of targets varies between the different modes of therapy but it is essential for counselors working in each mode to be clear what the targets are. An overall goal in every mode of therapy is to increase dialectical thinking.

TREATMENT STRATEGIES

Within this framework of stages, target hierarchies and modes of therapy a wide variety of therapeutic strategies and specific techniques is applied.

The core strategies in DBT are 'validation' and 'problem solving'. Attempts to facilitate change are surrounded by interventions that validate the client's behavior and responses as understandable in relation to her current life situation, and that show an understanding of her difficulties and suffering.

Problem solving focuses on the establishment of necessary skills. If the client is not dealing with her problems effectively then it is to be anticipated either that she does not have the necessary skills to do so, or does have the skills but is prevented from using them. If she does not have the skills then she will need to learn them. This is the purpose of the skills training.

Having the skills, she may be prevented from using them in particular situations either because of environmental factors or because of emotional or cognitive problems getting in the way. To deal with these difficulties the following techniques may be applied in the course of therapy:

1. Contingency management
2. Cognitive therapy
3. Exposure based therapies
4. Pharmacotherapy

The principles of using these techniques are precisely those applying to their use in other contexts and will not be described in any detail. In every form of DBT, even classical patient therapy, they are used in a relatively informal way and interwoven into therapy.

One of the reasons DBT adapts so well for the environment at The Ranch, is that it is inherently flexible. Contingency management is used throughout therapy, using the relationship with the counselor as the main reinforcer.

There are no “hidden agendas” either, the clear expectations of acceptable behaviors are posted, clarified and discussed openly and regularly. Care is taken to systematically reinforce targeted adaptive behaviors and to avoid reinforcing targeted maladaptive behaviors. This process is made quite overt to the client, explaining that behavior which is reinforced can be expected to increase.

A clear distinction is made between the observed effect of reinforcement and the motivation of the behavior, pointing out that such a relationship between cause and effect does not imply that the behavior is being carried out deliberately in order to obtain the reinforcement. Didactic teaching and insight strategies may also be used to help the client achieve an understanding of the factors that may be controlling her behavior.

The same contingency management approach is taken in dealing with behaviors that overstep the counselor's personal limits in which case they are referred to as 'observing limits procedures'.

Problem solving and change strategies are again balanced dialectically by the use of validation strategies. It is important at every stage to convey to the client that her behaviors, including thoughts feelings and actions are understandable, even though they may be maladaptive or unhelpful.

Significant instances of targeted maladaptive behavior occurring since the last session (which should have been recorded on the diary card) are initially dealt with by carrying out a detailed 'behavioral analysis'. In particular every single instance of suicidal or parasuicidal behavior is dealt with in this way. Such behavioral analysis is an important aspect of DBT and may take up a large proportion of therapy time.

In the course of a typical behavioral analysis a particular instance of behavior is first clearly defined in specific terms and then a 'chain analysis' is conducted, looking in detail at the sequence of events and attempting to link these events one to another. In the course of this process hypotheses are generated about the factors that may be controlling the behavior. This is followed by, or interwoven with, a 'solution analysis' in which alternative ways of dealing with the situation at each stage are considered and evaluated. Finally one solution should be chosen for future implementation. Difficulties that may be experienced in carrying out this solution are considered and strategies of dealing with these can be worked out.

Behavioral analysis can be seen as a way of responding to maladaptive behavior, and in particular to parasuicide, in a way that shows interest and concern but which avoids reinforcing the behavior.

At GATEWAYS for Youth & Families we regularly utilize 'case management strategies'. This is another way of saying we promote self-reliance. The basic idea is that the client should be encouraged, with appropriate help and support, to deal with her own problems in the environment in which they occur. Therefore, as far as possible, the counselor does not do things for the client but encourages the client to do things for herself.

WHY Does GATEWAYS for Youth & Families use DBT and EAT and similar counseling techniques?

It’s really simple. We think they work best for shaping and transforming lives. They stop people from acting in ways that interfere with their ability to move forward and give them tools to cope with the challenges that will come to them after they’ve left our care. It’s what we’ve seen work on people, what they come back to us time and again at the Ranch to report, to meet the new people who work at the Ranch, share their stories and reflect back on how they’ve changed and grown since their time with us.

Dyslin Ranch was first established as a 15 acre working ranch to house teenage boys who had aged out of the Children’s Industrial Home and teach them an occupation. Over the course of the next fifty years there was a shift in the delivery of social services and support of orphaned or neglected children became a function of the government, who contracted for services with the Ranch. Over time, we acquired 16 more acres and added a therapeutic treatment center for teenage boys and girls and offices to house our family support services at the Ranch location. We entered into a contract to house and treat juvenile offenders coming out of detention.

Through all the changes, we continued to use farming techniques as hands-on therapy and the basis for teaching independent living skills Our core values of self-reliance, personal responsibility and community service is consistent with the heritage of our organization and the nature of the people who settled the Pacific Northwest and founded GATEWAYS for Youth & Families. In fact, we’re expanding our emphasis on the rural character of our environment and using our natural setting to accentuate our therapeutic model.

The Dyslin Ranch is the location these days for more than just youth development and teen counseling. We’ve relocated our corporate headquarters there, along with our foster care case managers and Family Services, and we’ve added an early education center and after school programs for elementary age children to round out our continuum of services to children.

GATEWAYS for Youth & Families was founded as a private social services agency. The stated purpose was to care for children whose families were unable to provide adequate food, shelter, medical care or supervision because of death, illness, poverty or other disabling mental, physical or social conditions. GATEWAYS for Youth & Families philosophies and methods have been consistent through five generations.

From the beginning, parents were urged to provide such support as they could, and young people to actively participate in and financially support their own development. Moreover, the organization raised funds not only through seeking private donations and public support, but also in part through self-supporting commerce. The name, the way services are delivered and the words we use to describe those services evolved with the generations that followed; however, the core values and mission remain the same. We provide care and services to improve the lives of children when their families cannot. The mission in modern times is stated as Shaping Young Lives, Providing a Community Safety Net and Transforming Families so They Can Thrive Since 1890. The core values of the organization are more than just slogans, they are used as the guiding principles for every new program from co-parenting education to equine assisted therapy. We continue to serve children and their families and promote self-reliance, personal responsibility and community service.

WHY AN EQUESTRIAN CENTER AT GATEWAYS DYSLIN RANCH?

So, why horses? The bond between children and horses is legendary. But the legends are based in reality, and now in medical science. Equine assisted therapy is an effective tool for those deemed “at-risk” - who require therapy to help them stay on the right track, or to find the right track. It also works well for children who are recovering from the effects of violence, abuse, or neglect. Furthermore, it is a tool to teach children who have not suffered any particular ill effects from the adults in their life the core values treasured by the GATEWAYS organization, self-reliance, personal responsibility and community service. In our modern, urban-centered culture, even moderate to middle-income level children are denied this character building experience due to lack of funds or program resources. The Jessie Dyslin Ranch Equestrian Center’s Equine Assisted Activities Programs will offer opportunities for growth and healing to children who would otherwise not have them.

Equine Assisted Activities include personal development, education and therapeutic interventions and utilize experiential learning. Experiential learning is learning by doing. It occurs when a person is interacting with the environment, including the people, animals and situations involved. Therapeutic Riding is a growing and widely-accepted treatment for rehabilitating a range of physical, mental, and emotional disabilities. Riders experience increased self-confidence and improvement in strength, balance, coordination, attention span, language and social skills. It involves an ongoing therapeutic relationship with clearly established treatment goals and objectives developed by the counselor in conjunction with the client. The therapeutic team includes an appropriately credentialed mental health or rehabilitation professional and an equestrian specialist.

Equestrian Assisted Therapy is more than “horsemanship and riding classes." Equine therapy, which involves clinical professionals, has been shown to be effective in treating a variety of mental health and human development needs and behavioral issues, such as attention deficit disorder, substance abuse, eating disorders, abuse issues, depression, anxiety, anger management, conflict resolution, relationship problems and communications.

Horses offer several advantages. For one thing, their size offers a perfect opportunity for some to overcome fear and develop confidence. "Accomplishing a task involving the horse, in spite of those fears, creates confidence and provides for wonderful metaphors for dealing with other intimidating and challenging situations." Horses are social animals, with distinct personalities, attitudes and moods. Working with them and caring for them requires effort --there's no easy way out. No quick tricks.

“A lot of animals are used in therapy,” explained one. But with horses, there's the respect factor. “You can't bully them. If you give respect, you get respect.” Horses have the ability to mirror exactly what human body language is telling them. People complain that the horse is stubborn or antagonistic. “But the lesson to be learned is that if they change themselves, the horses respond differently.”