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Posted: Jan 31, 2011 07:23

DIALECTICAL BEHAVIOR THERAPY WITH GIRLS IN WILDERNESS

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by Kirsten Bolt, M.Ed., LAMFT
Primary Therapist for Girls Groups
Aspen Achievement Academy
Loa, UT
435-836-2472
kbolt@theaspenacademy.com

Wilderness provides an excellent setting for girls to practice the four key skills of dialectical behavior therapy (DBT): mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. This model was developed to help clients struggling to manage overwhelming emotions and associated self-destructive behaviors. Much evidence1 suggests that DBT is effective in treating such intense issues as: self-injury; suicidal thoughts; communication and interpersonal relationship conflict; poor management of anger, depression, anxiety, or other difficult emotions; and substance abuse.

When situations and/or emotions become too overwhelming, we naturally look for a means of control and coping-the question is whether our methods are healthy or not. When they are not, our negative coping behaviors often become self-reinforcing. For example, by exploding on her parents, Katy might immediately reduce her stress regarding school and feel better, suggesting to her that exploding on her parents works to relieve her stress. However, that short-term fix is only temporary and actually creates more problems. Because our emotions, behaviors, and thoughts are so interconnected, Katy probably also experiences secondary emotions of embarrassment, guilt, or shame, which feed her negative thoughts about herself or even her parents (if projecting that blame). In turn, those negative thoughts feed her negative emotions of depression and anger, thereby creating a self-reinforcing cycle that can trigger self-injurious behaviors, substance abuse, more interpersonal problems, or other negative coping mechanisms.

Underneath these behavioral problems are issues of poor distress tolerance, emotion regulation, interpersonal effectiveness, and mindfulness: the core skills of DBT. This article will explain how DBT used in a wilderness therapy setting can be powerful and very effective for girls struggling with issues related to self-esteem, overwhelming emotions, communication, identity, and the associated self-destructive behaviors.

Why use DBT in wilderness?
Not only is DBT valuable for adolescent girls attending traditional therapy at home, residential treatment centers, or therapeutic boarding schools, but it also is quite effective in wilderness therapy programs. Many aspects of wilderness make it an ideal setting for DBT: using Nature as a catalyst for change; continuous supervision and intervention; daily challenges that necessitate healthy coping skills; and group dynamics that facilitate healthier communication.


  • There is something powerful simply being in Nature. Time slows, one's heart rate slows, and the stressors of life often dissolve. If you have ever noticed feeling calm while sitting in a city park, alert while walking to work, or centered after sleeping under the stars, you know what I mean. Your senses awaken, you key into your surroundings, and the only moment that exists is the present moment. Returning home or to work can often feel overwhelming! Wilderness helps girls practice the core DBT skill: mindfulness. In addition, removing the distractions, electronics, and hustle of the "real world" forces girls to look at themselves and their issues: there is no hiding or running from one's problems in wilderness. Solo experiences are particularly valuable to this end, during which girls sit alone in the silence of the desert.


  • Field instructors, well trained by therapists, spend every minute of every day supervising, intervening, correcting, and coaching girls in wilderness therapy programs. If a teachable moment presents itself at 10pm, the group can stop their routine to address the issue, thereby helping internalize interpersonal effectiveness, emotion regulation, and distress tolerance DBT skills. This level of care is unique to wilderness therapy, even surpassing that of residential treatment.

  • Living outdoors is not easy and girls frequently think they cannot do it. As such, girls have many great opportunities for daily challenges: challenges that tax their stress and coping levels. Learning to make a bowdrill fire using a couple pieces of wood and a rock often results in frustration and then giving up, yelling, walking away, or other poor responses. Hiking while carrying a third of your weight on your back can stress anyone. Earning natural or logical consequences when not prepared for the day or a rainstorm can quickly spin girls into their negative coping mechanisms, which can then be addressed directly. These daily challenges help girls internalize distress tolerance and emotion regulation skills. As they say, "crisis equals opportunity.


  • Finally, putting a group of girls together, who generally have poor communication skills, and asking them to work together to push a handcart, get camp chores done, or support each other frequently leads to interpersonal conflict and therefore, opportunities to practice interpersonal effectiveness skills, such as being assertive, expressing emotions and thoughts constructively, and negotiating.

How can DBT be used in this setting?
Some ways in which I use DBT principles to work with girls in wilderness include individual therapy sessions; group therapy sessions; experiential activities; handouts; and modeling of the skills by therapist, field instructors, and senior group members.

  • Individual therapy sessions allow me to focus on girls' unique needs. During these meetings, I review and guide the communication between a girl and her parents, process events from the week, teach specific skills in more detail, and review specific assignments (e.g., an emotion log, in which they track their emotions during the week, connect them to specific events, and recognize their healthy or unhealthy responses).


  • Group therapy sessions make dissemination of information to the whole group possible, thereby encouraging girls to work on skills together, normalizing their experiences of using unhealthy behaviors to manage overwhelming emotions, and having fun.


  • Girls learn specific skills as a group, such as DEAR MAN (Describe, Express, Assert, Reinforce, stay Mindful, Appear confident, and Negotiate) and then practice that skill to improve communication, getting peer and staff feedback.


  • I-feel statements are taught and used in the same manner. Several times throughout the day, everything stops when someone wants to share how she is feeling using an "I-feel statement," after which another girl will reflect it back to her, ensuring understanding and reinforcing the importance of listening in communication. Frequently, staff or other students will stop someone giving an I-feel statement in mid-statement to coach her on the format and delivery.


  • We make self-care boxes as a group: the girls collage on the outside how they want to be seen or are seen by others (masks) and on the inside how/who they really are. In the box, they then place ideas for self-care, coping skills, mindfulness exercises, and communication tools that they can take home.


  • Groups can also be experiential to facilitate deeper learning and retention of the skills. For example, I often lead a group on assertive communication in which the girls act out different styles of communicating, using real-life examples.


  • Girls can carry simple handouts to remind them of the specific skills they are practicing, helping our visual learners. For example, all the girls I work with carry a couple pages of distress tolerance exercises and a DEAR MAN handout.


  • Modeling of these DBT skills is done by the therapist during weekly visits, by the field instructors as previously described, and by the senior group members who can coach the newer girls.

Wilderness can be a powerful setting for anyone, and it can be particularly potent for adolescent girls struggling with issues related to emotions, self-esteem, identity, communication, and the self-destructive behaviors that are frequently associated with those issues. Incorporating DBT skills training and practice into a wilderness therapy program, girls can develop a skill-set transferable to home, saving themselves and their relationships with others.

References:
1. Summary of research current to 2007, supporting DBT's effectiveness:
http://behavioraltech.org/downloads/dbtSummaryOfData.pdf

2. Frauman, E. (2010). Incorporating the concept of mindfulness in informal outdoor education settings. Journal of Experiential Education, 33(3), 225.


Aspen Achievement Academy is a wilderness therapy program located in the high desert of southern Utah that provides "at risk" adolescents ages 13 to 17 with experiences that promote the development of self-discipline, confidence, problem-solving skills and a healthy lifestyle. Using insight-oriented individual, group and family therapy and modern rites of passage, troubled teens identify healthy ways to bridge the gap between adolescence and adulthood. For more information please visit www.aspenacademy.com.


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