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©2010 Gestalt Intl Study Center

Making Contact with the

Self-Injurious Adolescent: Borderline

Personality Disorder, Gestalt Therapy, and

Dialectical Behavioral Therapy Interventions

L Y n n W I L L I A M S , p h . d .

A B S T R A C T

Gestalt therapists who work with children and adolescents will
inevitably encounter clients who present self-injurious behaviors.
This article provides a combined Gestalt and Dialectical Behavior-
al Therapy theoretical basis for understanding and intervening
with these challenging individuals. In this model, core Gestalt
theoretical ideas overlap with a select group of DBT principles,
which include awareness, mindfulness, sensory body experience,
emotion regulation, acceptance, and the client/therapist rela-
tionship as agents of change. These principles can be integrated
to create a holistic and effective approach with related interven-
tions for treating self-injurious adolescents. Gestalt therapists
can use these integrated interventions as “awareness tools” to
promote the developmental process and encourage maximum
growth of the client through increased awareness of themselves
and their contact processes, and through improved self-regula-
tion skills.

Gestalt Review, 14(3):250-274, 2010

Lynn Williams, Ph.D., is a licensed psychologist who practices a wholistic

approach to psychotherapy. She incorporates integrative practices such as

meditation, spirituality, yoga, and nature with psychotherapy for optimum

healing and growth. She has conducted national and international

workshops illustrating the power of psycho-spiritual approaches to growth

and development.

Leslie S. Greenberg, Ph.D., served as Action Editor on this article.

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Recent research shows that self-injurious behaviors are on the rise among

teens (Brody, 2008). For example, in one study of girls ages 10-14, the findings
indicate that 54% of participants had intentionally injured themselves at least
once in their lifetime (Hilt, Cha, & Nolen-Hoeksema, 2008). Researchers have
put forth numerous theories to explain the causes of these types of behaviors
and have linked self-injury and suicidal ideation to a variety of diagnoses that
include Major Depressive Disorder and Bipolar Disorder, among others. This
article will focus on one of the most widely recognized theories that links
recurrent self-injurious behaviors with Borderline Personality Disorder (BPD).
A discussion of BPD and self-injury in a popular magazine discloses that: “Bor-
derlines are the patients psychologists fear the most. As many as 75% hurt
themselves, and approximately 10% commit suicide” (Cloud, 2009). Given
that Gestalt therapists who work with children and adolescents will inevitably
encounter clients who present self-injurious behaviors, I shall provide an inte-
grated Gestalt theoretical basis for understanding and intervening with these
challenging individuals.

I have drawn upon a growing body of research as well as personal ob-

servations in constructing a therapeutic model that integrates core Gestalt
theoretical ideas with principles selected from Dialectical Behavior Therapy
(DBT). Recent literature shows that if, on the one hand, Gestalt therapy is use-
ful in the treatment of Borderline Personality Disorder, suicidality, and other
self-injurious acts that are destructive to the body such as eating disorders
(Young & Lester, 2001; E. Greenberg, 1989; Blaney & Smythe, 2001), on the
other hand, DBT is arguably one of the most effective treatments for the sui-
cidal and self-injurious behaviors of people diagnosed with BPD. The founder
of DBT, Marsha Linehan, led a two-year National Institute of Mental Health
(NIMH) study that showed this therapy’s effectiveness in decreasing self-inju-
rious and suicidal behaviors by one-half when compared to other treatments
(Linehan et al., 2006). A more recent study conducted by McMain et al. (2009)
has found that the effectiveness of DBT relative to “an active, manualized
approach derived from APA recommendations” is still a contentious issue (p.
1). By using APA practice guidelines for the treatment of patients with BPD,
which included case management, dynamically informed psychotherapy, and
symptom-targeted medication management, experts in BPD and suicidality
were as successful as DBT practitioners in treating suicidal and nonsuicidal
self-injurious behaviors. On the basis of my own clinical experience of working
with self-injurious adolescents, I have found it effective to use an integrative
model, which incorporates DBT and Gestalt therapy principles. In this article
I explore the Gestalt therapy principles and growth themes, also found to be
core to the DBT approach, in order to create an integrative model for work-
ing with self-injurious clients based on awareness and acceptance, and on

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support-related interventions.

In establishing a framework for DBT, Linehan incorporated Gestalt therapy

principles in addition to a variety of other therapeutic approaches (Katz,
Gunasekara, & Miller, 2002). Like Gestalt founder Fritz Perls, Linehan was a
passionate student of Zen Buddhism and spent long periods of time in vari-
ous Zen monasteries. Not surprisingly, Zen Buddhist principles such as present
moment awareness and acceptance appear as primary components in the
therapeutic models developed by Perls and Linehan (Eynde, 1999; Linehan
1993a). Both models emphasize using awareness, mindfulness, sensory body
experience, emotion regulation, acceptance, and the client/therapist relation-
ship as agents of change. Linehan joked that she could have named DBT “Zen
Behavior Therapy” but was afraid people would not have taken her work
seriously (Butler, 2001).

Some Gestalt therapists have commented positively on the similarities and

overlap between the two approaches. In an unpublished manuscript Matzko
(2003) writes, however globally, that “DBT is philosophically so similar to
Gestalt therapy that one could, without reservations, call it by that name”
(p. 299); implicit, of course, is that even though these models use some of
the same language and processes they are not exactly alike. Matzko (2003)
promotes a synthesized Gestalt therapy approach in working with addiction/
mental health troubled clients, incorporating Gestalt principles, DBT, and the
therapeutic community. Similarly, in commenting on cognitive-behavioral
therapy (CBT), which is an underlying component of DBT, Fodor (2009) de-
scribes DBT as an experiential, process-oriented CBT that incorporates many
aspects of both schema theory and Gestalt therapy; as such, it is a model of
integration between Gestalt and CBT.

While Matzko and Fodor rightfully point to similarities between these two

therapeutic models, it is also important to recognize and respect the differenc-
es. DBT is primarily a cognitive-behavioral treatment for BPD that emphasizes
four areas of skill: mindfulness, emotion regulation, interpersonal effective-
ness, and distress tolerance. This therapeutic approach elicits change primarily
through psychoeducation, a validating relationship, cognitive restructuring,
problem solving, behavior chain analysis, and behavior modification. Its skill-
based emphasis is similar to a classroom style of learning, and its use of skills
is related to the deliberate use of will power. As previously mentioned, Fodor
(2009) recommends that when using Linehan’s model, the Gestalt therapist
can and should incorporate and emphasize the experiential and process-
oriented elements. Building upon the ideas of Fodor (2009), Matzko (2003),
and others, I propose an integrated approach to working with the suicidal,
self-injurious teen with BPD that focuses on change through experiential and
process-oriented modalities. This approach enables the Gestalt therapist to

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help the client build awareness, improve self-regulation, and reconnect with
disowned parts of the self, while increasing her ability to make contact with
self, others, and the world.

By focusing on the core Gestalt elements already inherent in the DBT

framework, I have enhanced rather than detracted from my work as a Ge-
stalt therapist. The agency I work for was eager to implement DBT strategies
with our residential clients because of the documented effectiveness of this
therapeutic approach. After receiving training in DBT, I realized that some
of the principles and techniques overlapped with my Gestalt approach, and
that I already had used some of them in my work. Over the past several years,
the agency has assigned to my care some of the most highly challenging
self-injurious, suicidal, borderline adolescents who were unable to function
in the community and needed to be in a residential treatment setting. By
employing certain overlapping strategies as part of a comprehensive Gestalt
therapy approach, I found I could help some of my young clients go from daily
self-injurious and suicidal behaviors to a healthier level of functioning that
enabled them to return to the community.

Principles of Change: Dialectics and Acceptance

Dialectics is a primary agent of change in both Gestalt therapy and DBT. In

discussing dialectics and Gestalt therapy Linehan (1993a) writes:

The emphasis on dialectics in DBT is most similar to the therapeutic
emphasis in Gestalt therapy, which also springs from a wholistic sys-
tems theory and focuses on ideas such as synthesis. Interestingly, the
newer cognitive therapy approaches to BPD . . . explicitly incorporate
Gestalt techniques. (p. 22)

A core dialectical strategy of both Gestalt and DBT is the continuous balance
of acceptance and change. This view encourages both the therapist and the
client to hold the dialectical tension between full acceptance of the client,
their behaviors, and what is in the moment while also striving for change. In
the paradoxical theory of change, change occurs when the client fully identi-
fies with her current state (Beisser, 1970). By promoting this judgment-free
atmosphere of acceptance and by being open to “what is,” the therapist
paradoxically also facilitates a context of change. Linehan has described her
model, which is laced with Zen ideas, as a “technology of acceptance” free of
religious nuances (Butler, 2001). Her model is in line with the paradoxical the-
ory of change and posits that the therapist can promote therapeutic change
by simply accepting and holding a dialectic with the client. For example, Line-

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han explains that an essential dialectic for the therapist to convey to the client
is: “You have to change–and you are perfect as you are” (Butler, 2001).

Instead of attempting to extinguish or change the target behavior, Gestalt

therapist McConville (2001) encourages the therapist working with adoles-
cents to recognize the developmental value in the “problem,” and to support
and unblock the developmental process. He recommends asking the follow-
ing two questions to help the therapist assess the “dysfunction” related to the
individual and the environment in the developmental process, and to develop
related clinical strategies and interventions:

• How is this child’s environment providing, or failing to provide, challenges

to which the child must adapt and reorganize?

• How is this environment providing, or failing to provide, supports for the

child as he/she mobilizes to accept these challenges? (p. 48)

Oftentimes parents of self-injurious teens just want the behaviors to stop, and
they place pressure upon the therapist to extinguish them successfully. In em-
bracing an acceptance and change dialectic, however, part of the therapeutic
work of the client, parents, and therapist is to accept fully and tolerate all cir-
cumstances and emotions in a nonjudgmental way before change can occur.

In Gestalt therapy, all behaviors are also thought of as “creative adjust-

ments” between the organism and the environment (Perls, Hefferline, &
Goodman, 1951, pp. 288-292). The Gestalt therapist is responsible for helping
the client look at the power and process of these creative adjustments, and
for recognizing how they have developed and served both positive and nega-
tive functions in the person’s life.

The self-injurious client presents a special challenge to the Gestalt therapist,

who should prioritize increasing awareness in a nonjudgmental framework
while, at the same time, managing potential life threatening behaviors. Young
and Lester (2001) have explored this issue in their Gestalt therapy approach to
working with the suicidal client. They state that: “the counselor does not aim
to direct the clients, but rather free them for growth that is self-directed” (p.
68). Perls et al. (1951), for their part, avow that “the achievement of a strong
gestalt is itself the cure” (p. 273, emphasis in original). Although the therapist
must act in accord with his or her ethical obligations, these laws should not
be the primary driver and governor of the therapy. Young and Lester (2001)
encourage the Gestalt therapist not to shy away from exploring suicidal feel-
ings and to be an active crisis counselor by “acknowledging the clients’ sui-
cidal ideation and their psychological struggle, exploring their suicidal plan,
exploring their anger and underlying loneliness, helping them become aware
of their repressed emotions and ambivalence, and exploring options” (p. 65).

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LYNN WILLIAMS

Wheeler (1997a) discusses the struggle of the Gestalt therapist to promote
healthy autonomy when suicidal or ambivalently suicidal clients present them-
selves. He cautions therapists against automatically judging self-destructive
acts as “bad,” and of imposing their own perceptions, judgments, and values
that go against the initial goal of promoting autonomy.

Self-Development, Emotion Dysregulation,

Invalidation, and Shame

In addition to analyzing acceptance and change strategies, examining the

relationship between the individual and his or her environment is key to both
DBT and Gestalt strategies. Wheeler (2002) suggests that the self is inter-
subjective, and that self-development is a relational, intersubjective process.
Moreover, the Gestalt model poses that self-development and integration of
the self take place as a result of interactions within a relational context or
field (Wheeler, 2002). Robertson also emphasizes that attention to the self-
other process in adolescents is crucial because this process is directly related
to how we organize and transition through different life spaces (Toman &
Bauer, 2005).

Linehan’s biosocial theory of borderline personality disorder also examines

the interplay between the self-system and the environment. The biosocial
model proposes that the combination of biological dysfunction in the emotion
regulation system (high emotional sensitivity, impulsivity, and negative affec-
tivity), combined with an invalidating environment (invalidation of the child’s
emotions, inadequate coaching of emotion, and negative reinforcement of
aversive emotional expression), cause the pervasive emotion dysregulation
related to borderline personality disorder (Crowell, Beauchaine, & Linehan,
2009). The biosocial theory is somewhat similar to Gestalt’s interpersonal pro-
cess of self-development and field model in which inner and outer elements
of the field are connected and the presenting symptoms are a product of the
co-created environment of self and other. In discussing this model, Lee (2001)
writes that:

In order to understand someone’s behavior, we must understand the
person’s co-constructed map, the experiential context in which the
behavior’s exists. The behavior itself may be figural, but to under-
stand the meaning of this figure we must first understand the ground
from which it emerges; i.e., the person’s needs and perceived set of
possibilities for connection/disconnection in the environmental field.
(p. 254)

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A relational, field perspective enables the therapist better to assess, under-

stand, and intervene with pervasive emotion dysregulation and self-injurious
behavior. Recent Gestalt literature points to a linkage between the use of field
theory and self-other processes to help explain self-injurious behaviors and
the experience of shame. Therapist Lee (2001) finds a possible link between
self-injurious behaviors and shame and describes these acts as “the person’s
aware or unaware attempt to hide, avoid, and or cope with his experience of
shame” (p. 256). Gestalt theory posits that shame “occurs when an individual
discovers that some aspect of interior experience, some want or interest or
longing, is not sufficiently received and accepted in the social field” (McCon-
ville, 2001, p. 289). Lee and Ullman (2006) outline some key points related to
understanding and working with shame:

• Shame is always an attempt to protect.
• The only time you are in danger of experiencing shame is when you care.
• Where there is shame there is yearning–look for the yearning.
• Shame is experienced as information about the self when in reality it is in-

formation about our perception of the condition of reception of the field.

The field phenomenon of shame is linked to Linehan’s biosocial theory,

which describes an invalidating environment as a significant contributor to
the development of emotion dysregulation, a core feature of borderline per-
sonality disorder. The “invalidating environment” is one in which the child’s
personal experiences, responses, and emotions are disqualified or “invalidat-
ed” by others. Linehan’s invalidating environment is similar to what Wheeler
(1997b) has described as an absence of support and loss of connection with
others in the environment, which results in the experience of shame. This loss
of connection or “disconnect in the field” is not only with the external world
but also with the inner world and self. Wheeler notes that shame is the “af-
fect of that disconnect in the field” (p. 234).

While it is easy to point to invalidating behaviors and actions on the part of

caregivers in abusive and neglectful environments, examples also abound of
intentionally or unintentionally invalidating behaviors by caregivers in seem-
ingly supportive and positive environments. In interactions with her child,
the mother of one of my teenage clients provided a good example of un-
intentional invalidation. Whenever her daughter expressed an emotion, the
mother responded with suggestions for fixing the problem or for changing
the feelings. Her “fix-it” approach to these situations turned out to be under-
standable, given her position as a manager of a large company where profes-
sional survival depended upon the ability to solve problems. The approach,
however, was invalidating to her adolescent daughter, who was struggling to

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identify and express her own feelings in her family environment.

Adults who create and maintain invalidating environments often attribute

the child’s inability to solve problems successfully to essential flaws in character
or to negative attributes, such as lack of motivation. Oftentimes, perplexed
parents feel that the teen should just stop the self-injurious behaviors and
react with anger or disappointment whenever these behaviors recur. They
feel that the teen is not “trying” hard enough to stop. The borderline teen,
on the other hand, may vacillate between the opposite poles of emotional
inhibition in an attempt to gain acceptance, and extreme displays of emotion
in order to have her feelings acknowledged. These vacillations only under-
score the need for parents to listen to the emerging adolescent voice and to
validate their child’s feelings and experiences. The practice of validation does
not necessitate that parents agree completely with the teen’s perspective;
only that they validate their child’s feelings and experiences. By creating an
atmosphere of validation and support, parents ultimately act to promote the
child’s developmental process.

Therapists and significant others can fully validate the self-injurious teen by

adopting a perspective that the client never “fails” therapy or treatment, and
by viewing periods of self-injury and non-self-injury in a nonjudgmental way.
The therapist accomplishes this task by always honoring the client’s resistanc-
es, and by recognizing that clients are “doing their best.” The DBT framework
calls for practitioners to take a nonjudgmental stance as demonstrated by the
use of the mindfulness bell, which is rung whenever anyone in staff meetings
makes a judgmental statement about a client, a therapist, or themselves. The
bell’s ring signals a momentary need for pause and breath.

Anna: A Case Study

In the following sections, I suggest several overlapping Gestalt and DBT

principles to assist in the conceptualization and practical applications of an
integrated model to treat self-injurious adolescents. In a DBT approach the
therapist uses these interventions primarily as a means to shape the client’s
behavior, while the Gestalt therapist can use them as “awareness tools” to
promote the developmental process, increase self-regulation, and help clients
build a life worth living. In using the select interventions, I want to reiter-
ate the warning of E. Greenberg (1989), who advises the Gestalt therapist
to exercise caution when using techniques that increase the intensity of the
therapeutic experience with the borderline client. She urges therapists to go
very slowly and to do more preparatory work to help the client build a better
intrapsychic support system, because the borderline does not have the same
inner resources and may tend to fragment when stressed.

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In order to protect client confidentiality, I have changed the names and any

identifying information in the ensuing case study. Nine years ago, authorities
had removed Anna, age 6, and her biological brother, age 2, from the home
due to conditions of neglect and abuse and had placed them in county custo-
dy. The county put the children in foster care with the Stokes family, who fell
in love with the siblings and eventually adopted them. The Stokes reported
that Anna had been very compliant and had adjusted fairly well throughout
her childhood. They noted some anxiety issues, such as tendencies to hoard
food, and some social issues as well, but assumed that these behaviors were
related to her traumatic past. At around age 14, Anna’s symptoms worsened
and she experienced an aversion to attending school. In the home, her behav-
ior grew increasingly oppositional and defiant. Anna would not follow basic
home rules, and when the family attempted to implement consequences, she
remained un-phased. The county labeled her as “unruly and oppositional.”
She began cutting herself regularly and on several occasions took medications
in order to overdose. The parents placed their medications in a lock box, but
Anna broke into the box and ingested its medicinal contents. Her attempts
at chemical overdose took place outside the home as well; when visiting the
homes of relatives and friends, Anna stole medications for that purpose. She
had nine psychiatric hospitalizations within 6 months. After returning from
each hospitalization, within a few weeks or even days she would engage in
more self-injurious, suicidal behavior, necessitating her readmission for treat-
ment. It was at that time that the Stokes decided to place Anna in the residen-
tial treatment facility where I am employed, and that I began working with
her. Prior psychological reports speculated on reactive attachment disorder,
depression, borderline personality traits, and possible schizophrenic traits, as
she presented flat affect and disorganized thinking at times.

Co-Assessment, Treatment Hierarchy, and Validation Strategies

Upon her admission, the unit reported that Anna continued to carry out

attempts to cut and harm herself. In her initial therapy sessions, she was
pretty much nonverbal. If I asked a question, she would either not respond
or respond with “I don’t know.” She kept her head down, avoided eye con-
tact, and seemed withdrawn, while occasionally picking at old scabs on her
skin. Although she seemed disconnected, Anna seemed to indicate a desire
to be known through a variety of behaviors that grabbed my attention. For
example, she would doodle the name of her previous therapist on a piece
of paper during her session, or begin engaging in skin picking rather than
verbally answering a question. Lee (2001) connects the experience of shame
with a deep yearning for others to notice our individual selves or parts of

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ourselves. Therapists informed by the shame perspective acknowledge the
client’s self-injurious behaviors upfront in therapy and actively process them.

In order to join with Anna yet still honor her resistances, I used a co-as-

sessment approach and introduced the treatment hierarchy. Clemmens (2005)
emphasized the importance of co-assessment in the therapeutic work with
substance users. He defines it as a “collaborative discussion and attention
that both the therapist and the client(s) direct toward the client’s functioning
and interest” (p. 285). This approach contrasts with the role of the traditional
therapist who acts as a detached observer and makes independent judgments
and diagnoses.

In DBT, the therapy process initially begins with commitment from the client

to work on the goals based on a treatment hierarchy. In my view, the treat-
ment hierarchy is in line with a co-assessment process and gives the therapist
and client an opportunity to look collaboratively at treatment goals, symp-
toms, and issues. This hierarchy outlines target behaviors to be addressed in
terms of priority: 1) life threatening behaviors (suicidal and parasuicidal self-
injurious behaviors); 2) therapy-interfering behaviors (i.e., poor attendance,
non-collaboration with therapist); and 3) quality of life issues (i.e., frequent
use of crisis services, depression, neglect of medical problems). I typically pres-
ent this hierarchy in the form of a visual triangular diagram, because it is
easier for adolescents to envision and so set concrete goals for themselves
in the therapy process. An additional benefit of the treatment hierarchy is
that it allows both the client and the Gestalt therapist to check in continu-
ally about safety, and to know the best time to target specific behaviors. I
find that the treatment hierarchy is a non-threatening way to begin to discuss
the self-injurious behaviors openly, because it orients both the therapist and
self-injurious client to the priorities of therapy and emphasizes safety as a
principal one (Linehan, 1993a, 1993b).

As I drew the treatment hierarchy diagram in my session with Anna, she be-

gan to shift her gaze, periodically looking up with an expression of curiosity.
I explained the diagram matter-of-factly, an approach which caused Anna to
soften somewhat as she realized that I was not “forcing” her to change. Then
I outlined how safety would be our first priority and gave examples of suicidal
and non-suicidal behaviors. I used an acceptance and change strategy and
told her, “I understand how hard it is not to self-injure, and I know that for
some reason you need to do that. The therapy that we will be doing holds the
belief that you are perfect as you are and making changes could benefit you
as well.” In later sessions, I attempted to engage Anna in dialogue and asked
what she felt was perfect about herself and her life, and what she wanted to
change. Although Anna did not typically verbalize her feelings, over time she
began to offer some responses to my query. She said she hated her parents

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and wanted to live with her foster sister. She began to set some goals for her-
self, saying, “I want to get out of here . . . I want to see my cat again.” She then
related specific examples of her own self-injurious and suicidal behaviors that
represented target behaviors. We later transferred these target behaviors to
diary cards so she could track their frequency and intensity (described in the
next section).

Now that Anna had begun to voice some of her feelings, it became neces-

sary to create a validating environment that would support her emotional
experiences. Drawing upon the Stop Walking on Eggshells Workbook (Kreger
& Shirley, 2002), I trained the unit staff and her family in the use of validating
communication techniques to assure Anna that she was being heard, and to
help her develop an emotional language to describe her experiences. The fol-
lowing statements exemplify this type of validating communication:

• To me, it sounds like you may be feeling a little ________.
• I’m hearing ________. Are you feeling ________because of ________?
• I’m wondering if something I’ve said or done might have contributed to

your feeling irritable/angry/anxious________.

• I may be wrong about this, but I’m wondering if you’re feeling kind of

lonely/let down/betrayed/discouraged________.

• If this happened to me, I would be feeling ________. How about you?
(Kreger & Shirley, 2002, p. 143)

The Healing Power of Awareness

Through the process of awareness, the self-injurious client learns to utilize

fully her internal and external senses so that she can see self-destructive pat-
terns. Ultimately, the goal of both Gestalt therapy and DBT is to help the client
become self-responsible and self-supportive. By cultivating awareness within
the self-injurious adolescent, the therapist facilitates an examination of the
contact process and of related inhibitions or interruptions to that process that
prevent the client from achieving a self-regulatory state. Although the thera-
pist enters into the relationship with the primary objective of building aware-
ness, safety is a major factor when dealing with self-injurious adolescents.
Destructive acts to the body can intentionally or unintentionally have serious
consequences and, as discussed earlier, safety should always be a priority.

Tracking awareness through diary cards enables the client to develop a

more detailed account of her thoughts, feelings, and experiences. Traditional
DBT diary cards are typically one to two pages in length and have four gen-
eral sections: feelings, urges, behaviors, and skills (Linehan, 1993a, 1993b). A
teen-friendly version of the diary card can be found at the following website:

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www.ata4ceu.com/diarycard.doc

When working with teens, I personalize the cards and sometimes include

more detail about the behaviors, a broader range of emotions, and specific
skills we are working on. Each card is divided into columns that distinguish the
days of the week and has a list of feeling words. The client rates each feeling
on that specific day, using a scale ranging from 0 to 5, with 0 being the low-
est and 5 the highest. The next section uses the same rating scale and asks
the client to rate urges for particular behaviors according to the treatment
hierarchy, and whether or not they have acted on the urge. I am careful to
include both suicidal and non-suicidal self-injurious behaviors, so that they
can distinguish differences between the two. The last section focuses on skills
they are working on and tracks how the client has implemented them on that
particular day.

Initially, Anna refused to do the diary cards. She resisted this exercise by

ripping up the cards or by claiming to “forget” to do them. Other times, she
would fill out only parts of the card and “forget” to fill out the rest. I hon-
ored these resistances and creative adjustments and continued to attempt to
validate her feelings and to balance the dialectic between acceptance and
change. DBT regards a client’s failure to complete her diary card as an ex-
ample of treatment interfering behavior and sets the expectation that she
will complete the card at the beginning of the session before further dialogue
occurs. The therapist operating from this behaviorist perspective “rewards”
the client by paying attention or engaging in dialogue only after the card is
completed. Using my awareness and process-oriented approach, however, I
stayed present with Anna’s resistance, validated it, and encouraged her to pay
attention to her opposition. I reminded Anna that she continued to carry out
self-injurious behaviors, and she admitted that these behaviors were creating
negative consequences for her in her life. I instructed her that by completing
the cards she would develop the awareness necessary to process these behav-
iors. In the interest of shaping her behavior and motivating her once that had
occurred, I moved forward in our therapy and discussed other topics such as
her recent relationship issues. After about 20 minutes of silence, Anna com-
pleted her card and we processed the session. I praised her for being assertive
without self-injuring. In later sessions, Anna began to personalize her cards
more–she added and changed some emotions and details that she wanted
to track, wrote or drew in the margins, and at times used different colored
pencils to illustrate her meanings. It seemed like an alternative way to commu-
nicate with me, perhaps less threatening than face-to-face verbal communica-
tion. While her diary cards revealed some very strong emotions and urges, her
affect remained flat. The fact that Anna could not verbalize her feelings in
sessions but could write them on paper suggested that she was experiencing

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a “disconnect.” The diary card provided Anna with a more tolerable means by
which she could share her feelings with me, at the same time that it gave me
a window into the emotions and urges with which she struggled.

Mindfulness: A Present-Centered Approach

Within a present-centered approach, the therapist increases sensory, affec-

tive, and cognitive awareness (Yontef, 2005). Through the use of mindfulness
and embodied awareness and of here-and-now experiments, the therapist is
able to foster self-realization and balance. Perls (1970) stated, “To me, nothing
exists except the now. Now = experience = awareness = reality” (p. 14). Some
Gestalt therapists have related the use of directed and focused awareness to
the term mindfulness. For example, Hooker and Fodor (2008) explored the
value of mindfulness practices (featuring focused awareness training) in their
work with children. Gestalt therapist Stevens (1977) also described the mind-
fulness concept, suggesting that the attainment of fulfillment occurs “when
you stop emptying yourself by trying to fill yourself and simply let the world
fill you” (p. 269). In other words, practicing mindfulness can help self-injurious
clients be present in the moment and create more space within themselves to
“take in” the world, rather than filling themselves with their own overflowing
thoughts and emotions. The Gestalt therapist can help the client use mindful-
ness (or nonjudgmental focused awareness) as a means to accept what is and
to manage shifting affect and moods more effectively.

Although mindfulness exercises may have the benefit of relaxation, their

principal objectives are to help clients become fully present in the here and
now and to accept their current experience. In DBT, mindfulness builds pres-
ent awareness; through the use of focusing and breathing techniques, it helps
the client better observe, describe, and participate in her experience (Line-
han, 1993b). DBT recommends not only that therapists teach mindfulness to
clients but also that they practice it themselves.

To help self-injurious adolescents comprehend the meaning of mindfulness,

I use the following exercise, which can be performed in an office or pref-
erably outdoors around objects in nature (trees, flowers, etc.). I begin with
an explanation of mindfulness, saying that this concept refers to a state of
awareness in which the individual fully experiences the here and now and is
able to notice fully the colors, textures, and sounds of her environment in the
present moment. I demonstrate what I mean by taking a second to describe
my own sensory experiences at that particular moment. For example, I might
notice the hum of the light, the sound of a bird, the softness of the cushion
on my back, the firmness of the chair I am sitting on, or the way light strikes
the client’s hair.

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In one mindfulness exercise, I use a rain shaker stick or maraca that creates

a soft rattle. The therapist, along with the client, can make a maraca by using
rice or beans, plastic Easter eggs, or two paper plates (clients can decorate
the outside of the plates). The plates should be stapled together around the
edges, but a two-inch hole left to insert rice or beans before they are stapled
completely shut. To begin the exercise, I invite the client to walk around the
room and look at her surroundings while I shake the rattle as background
noise. Next I tell her that, when the rattle stops, she should look in detail
(with focused attention) at some area or object that catches her eye in the
present environment, and notice why that particular object stands out. I invite
the client to record her observations in a journal, if she wishes, and then ask
her to share them with me. This exercise often surprises both of us by dem-
onstrating how much we typically overlook because of our inattentiveness to
self in the environment.

Case Study Application

Initially, Anna resisted taking part in mindfulness exercises, so we tried

some simple breathing exercises that included periods of silence. Often Anna
could not tolerate the silences and, within seconds, would complain that the
experience had lasted too long. On the facility unit Anna rebelled against
designated “quiet time,” during which residents remained in their rooms and
did not make any noise. I realized that, in certain ways, Anna felt threatened
by silence. In performing the “observe the room” exercise described above,
Anna focused her attention on items in the room’s shadows, on variations
in the light’s hue, and on subtle sounds produced by the air-conditioner. By
taking part in this activity, Anna became better able to tolerate silence and
demonstrated to me her strong attention to detail. Anna enjoyed drawing;
thus, in subsequent sessions, we performed mindfulness activities in which
she drew various objects in the room in as much detail as she could. Exercising
nonjudgmental focused awareness through drawing seemed to give her some
relief from the constant inner turmoil she typically experienced.

Because Anna was unable to tolerate basic meditation type breathing ac-

tivities, we did some simple yoga exercises such as the “dog and cat pose”
and the “forward bend.” In the dog and cat pose, the person is on hands and
knees and moves the spine upward and downward, while coordinating inhal-
ing and exhaling breath with the movements. In the forward bend the person
is standing and, on the exhalation, bends at the hips to touch the floor or the
ankles, breathing several times. While in the pose we incorporated the so-
called “what” skills of mindfulness in DBT to help her articulate and develop
a nonjudgmental focus in relation to her experience (Linehan, 1993b). These
“what” skills within the mindfulness module of DBT can be paraphrased as

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follows:

• Observe–this skill helps the client learn how to observe the environment

non-judgmentally, both within and outside of herself.

• describe–this skill helps the client express, without the use of judgmental

statements, what she has observed.

• participate–this skill enables the client to focus fully on the activity in

which she is engaged.

As Anna developed these skills, she became aware of the multitude of judg-

mental thoughts that had plagued her inner world, and had interfered with
her ability to experience the moment and the connection with her body. I
asked her to substitute these thoughts with nonjudgmental ones, and then to
re-focus on her breathing and body awareness. Bridging the mind and body
seemed to heal a deep divide, with which she had previously coped by trans-
forming her body into an object for self-destructive behaviors, or by wear-
ing over-sized clothing to hide her shape completely. Having gained a sense
of empowerment from these yoga exercises, Anna decided to teach them to
other residents within the treatment facility. For me, Anna’s efforts to teach
yoga to others not only enabled her to let go of some of her bodily shame, but
also contributed to the growth of a sense of collective belonging that had so
often evaded her in the past.

Emotion Regulation: Behavior Chain Analysis

By creating a validating environment, the therapist allows the self-injurious

client to accurately label and understand feelings that either she and/or
people in invalidating environments had previously overlooked or discarded.
The teen diagnosed with BPD typically replaces those discarded feelings with
self-injurious behaviors. Validation of the client’s feelings and experiences,
however, teaches her to trust her own responses to events.

Gestalt therapists have linked disruptions at the sensation phase in the cy-

cle of experience to Borderline Personality Disorder. Melnick and Nevis (1998)
have found that in this phase “individuals cannot easily tolerate, manage, or
translate these sensory stimuli into acceptable and manageable forms and
figures” (p. 435). In describing the behavior of clients with substance abuse or
addiction problems, Clemmens (2005) states that they jump from the sensa-
tion phase directly to the action phase; in so doing, they learn to interrupt
needs and sensations because action becomes the primary figure. In similar
fashion, self-injurious behaviors become a constant figure in the mind of the
borderline adolescent, thus interrupting her ability to manage important sen-

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sations and needs. Simeon and Hollander (2001) have differentiated these
self-injurious behaviors according to various classifications such as stereotypic,
compulsive, major, and impulsive types, depending on the type of behavior,
tissue damage, rate, and pattern of behavior. The fact that Gestalt therapy
views all behavior as a “creative adjustment” leads the therapist to collaborate
closely with the client, to bring awareness to the details of the self-injurious
behavior, and to uncover the related functioning of the behavior. An integrat-
ed DBT/Gestalt approach helps the client increase awareness to the function
of the self-injurious behaviors in order to self-regulate these behaviors. When
people can self-regulate, they are in harmony with themselves and free from
blockages or interruptions to their experience. The self-regulating individual
enjoys full contact between the self and the environment and is able to adjust
to ever changing external and internal stimuli.

Behavior chain analysis is a common DBT intervention that builds aware-

ness of the self-harming behavior. It requires the client to list thoughts, physi-
cal sensations, feelings, events, and vulnerabilities related to the behavior, as
well as how she might have intervened differently or “interrupted the chain”
(see, for example, http://www.dbtselfhelp.com/html/behavior_chain_analy-
sis.html).

Case Study Application

Although Anna typically remained sullen and quiet in session, on a daily ba-

sis she tracked intense anger in her diary cards. In her behavior chains, Anna
frequently left out any words of emotion, choosing instead to jump quickly
to self-injurious action. For instance, on one chain Anna wrote: “peer yelled
at me - I told her to leave me alone - went to room - cut self.” In therapy,
I helped Anna expand her awareness of the event by including body sen-
sations, thoughts, and feelings. As she did so, her behavior chain analyses
began to uncover many of the suppressed emotions and unexpressed needs
that arose in daily situations and contributed to her self-injurious behaviors.
A subsequent behavior chain looked like this: “argument with mom on phone
- anger - tension in chest - I think ‘mom doesn’t understand me’ - hard to
breathe - sadness - urge to cut - think I may feel like failure if I cut but may feel
relief.” In our therapy session, we explored this chain and discussed alterna-
tive ways that Anna could manage the identified feelings and urges. For ex-
ample, we discussed using relaxation techniques prior to phone conversations
with her mom; journaling to help her express anger; exercising or taking a hot
bath to help her reduce physical tension; and expressing feelings of sadness
rather than her typical anger. The behavior chains provided Anna with insight
into how both external and internal stimuli led to the urges. Having become
aware of this process, she could more effectively intervene and self-regulate.

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Anna’s self-injurious behaviors did decrease and, in subsequent sessions, she
seemed better able to tolerate, label, and express a variety of emotions. In
time, she began to express her feelings to others outside of the therapy ses-
sion, including to her parents.

Distress Tolerance: The Body and Self-Soothing

Self-injurious clients are often dissociated from their bodies and can ben-

efit from activities that help them become open to their present mind-body
experiences. Clients with borderline personality issues often have a history of
childhood sexual abuse, which is arguably an extreme form of invalidation.
Gestalt therapist Frank (2001) explored how the traumatized body does not
provide a healthy container for feelings and prevents emotions from emerging
naturally and spontaneously. She also showed how somatic Gestalt interven-
tions can unlock these bound patterns in the body. Toman and Bauer (2005)
described self-injurious behaviors as a disruption in the developmental line re-
lated to the body (body needs and impulses) and to problems in establishing
bodily independence. Once body sensations are brought into awareness and
made manageable, awareness, the second phase in the cycle of experience,
can emerge.

In DBT there are four Distress Tolerance strategies: distracting, self-sooth-

ing, improving the moment, and focusing on the pros and cons (Linehan,
1993b). For example, the strategy of self-soothing utilizes the five senses (vi-
sion, hearing, smell, taste, and touch) to encourage mindfulness and bring
comfort to the client when she is distressed and experiencing difficult emo-
tions. Perls (1970) often said, “Lose your mind and come to your senses” (p.
38). Through the creation of “comfort kits,” a common activity in which the
client gathers together an array of self-soothing items (Lowenstein, 1999), the
therapist can help the client induce relaxation in times of distress. The “kit”
consists of a plastic ziploc bag or a shoebox in which the teen places small,
easily portable items to represent each of the five senses. Kits might include
the following items: Visual: pretty picture, art piece, paint or crayon to draw
something, goo tubes; Auditory: Hearing-CD with favorite music, something
that makes sound; Smell: scented body lotions or sprays, scented candles,
potpourri; Touch: squishy stress balls, cotton balls, velvety and silky pieces of
fabric; Taste: chocolate, herbal teas, raisins.

Case study application

In my office I have a sensory basket that contains a variety of self-soothing

items. Both children and adults often gravitate towards it and enjoy playing
and experimenting with its varied content. Items related to smell held the

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most appeal for Anna. We easily constructed a small comfort kit for her to
take with her, and she proceeded to implement smell sensory interventions
more intentionally in her life. For example, she put air fresheners in her room
and used scented body washes and sprays. Anna felt that these small inter-
ventions had a calming effect.

Anna suggested that she bring her comfort kit to family therapy sessions.

We identified those feelings evoked by family therapy, which self-soothing
might help her tolerate better. She said, “My parents stress me out and fam-
ily therapy stresses me out”; she proceeded to identify feelings, especially
angry and sad ones, from her diary card. She added that she had always felt
frustrated and sad with her family because they never understood her. At the
following family therapy session, Anna brought her kit and used her squishy
ball while we talked. I found her participation to be much better when she
was able to engage physically in something with her hands.

I urged Anna to disclose to her family those feelings that she had identi-

fied prior to the session. While averting their gaze and forcefully squeezing
the ball, she told them about feeling misunderstood and less valued than
her brother. In response, her mom began to say that she gives them equal
time, and that her brother has specific needs. She went on to say that she
has been so focused on Anna since she has been in residential treatment that
she feels she is neglecting the brother. I immediately interrupted her mother
and prompted her not to explain but simply to validate Anna’s feelings. I had
to coach her mother to say a validating statement like, “I hear you feel mis-
understood and less valued, and I am guessing that makes you feel sad.” Her
mother’s typical pattern of response to Anna was to explain, try to fix the
situation, and express her own feelings, so that it was hard for her to validate
her daughter’s emotion. As stated above, Anna’s mother was a high-level
manager who was valued in the workplace for her excellent ability to “fix”
problems, but her “fix-it” approach proved to be invalidating in interactions
with her daughter. After her mother assumed a more validating approach,
Anna became better able to stay with her particular feeling; consequently,
mother and daughter reached a deeper level of dialogue. In this instance, I
believe that Anna became more able to tolerate her feelings physically and
emotionally, and to disclose them to her family, partly because she had en-
gaged in a self-soothing activity with the squishy ball, and partly because the
validating environment had provided support for those emerging feelings.

Anna used her squishy ball often and found that she could better self-regu-

late and be more interpersonally effective when she kept her hands occupied.
After this discovery, she noticed that her self-injurious behavior had revolved
around manual activities, such as picking scabs, carving her arms, etc. She
then conducted an experiment in which she kept her hands busy for a week.

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She carried a small paddleball with her everywhere; the constant motion of
the ball, and the sound of the paddle and ball, seemed to allow her more
engagement with others in the world. While using the paddleball, Anna grew
increasingly more verbal and garnered much positive attention from others,
who challenged her to see how many consecutive times she could hit the ball.
She began to engage with others as they passed the paddleball among them
and competed for the most hits. Those interactions also seemed to foster a
sense of communal belonging, which helped Anna let go of previous feelings
of shame.

Interpersonal Effectiveness: The Therapist-Client Relationship

In both Gestalt therapy and DBT, the therapist-client relationship serves as

one of the foundational elements to promote change in the self-injurious cli-
ent. Growing up is not an easy task. Often teens have difficulty making “good”
contact because they enter therapy distressed, anxious, angry, sad, etc., and
then withdraw, cut off parts of themselves, or repress emotional expression
(Oaklander, 1997). In recognition of this fact, the integrated approach calls
upon the therapist to accept fully the position the teen currently occupies
in the developmental process. Gestalt therapist E. Greenberg (1989) states
that the borderline dilemma is that the individual “goes through life forever
seeking a safe way to get the love, nurturing, and permission to separate
and individuate” (p. 15). The therapeutic relationship provides the borderline
with the ideal, safe place in which she can finally resolve this dilemma. In it,
she experiences full acceptance, while at the same time receiving permission
to separate, resist, and individuate. McConville (2001) uses the terminology
of “connecting and disembedding” (p.38) to describe the adolescent’s devel-
opmental tasks. He contends that, initially, teens are connected to a “family
field” but then strive to form a self that is separate from the family or, in
other words, to “disembed” themselves. This process allows the adolescent
to develop a sense of separateness and individuality, while maintaining con-
nection. Polster and Polster (1999) state: “In moments of good contact, there
is a clear sense of oneself and a clear sense of the other” (p. 105). Although
the self-injurious adolescent strives to make good contact with her individual
self and with the environment, she ultimately does so in a self-destructive way
due to her problems with self-regulation and the effects of an invalidating
environment. On this subject, E. Greenberg (1989) writes: “Becoming border-
line was a healthy thing to do. . . . Borderline. Personality Disorder began as
a healthy adaptation to an unhealthy home situation” (p. 11). In contrast to
the invalidating home environment, the therapeutic relationship offers the
teen the ideal place in which to make social connection without experiencing

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shame. It also allows her to experiment with and practice a variety of ways
to make contact with another person and the environment. Yontef (2005)
describes how the therapeutic relationship facilitates the healing process:
“Change happens through the contact between the therapist and patient.
The emphasis is on ‘meeting’ the patient, on contact without aiming” (p. 95).

Often outpatient psychotherapy is held at weekly intervals. In between

sessions, clients might have a hard time building on the work that was done
in the previous session, or they might experience crisis. With self-injurious
clients, I recommend therapy twice a week, with brief telephone consulta-
tions (during crisis and non-crisis) as needed, to increase the generalization
of awareness, contact, and self-regulation skills in their everyday lives. DBT
recommends individual therapy once a week, a weekly two-hour DBT skills
group, and telephone consultations between meetings.

Telephone consultations are common in DBT and help bridge the work be-

ing done in the therapy office. They provide another means by which the
client can gain validation and support, while decreasing the feelings of shame
frequently associated with self-injurious behaviors. Miller, Rathus, and Line-
han (2006) write: “Phone calls have several important purposes: 1) to provide
coaching in skills and promote skill generalization 2) to provide emergency
crisis intervention 3) to break the link between suicidal behaviors and thera-
pist attention by inviting contact for ‘good news’ and 4) to provide a context
for repairing the therapeutic relationship without requiring the client to wait
until the next session” (p. 75). Telephone consultations between sessions al-
low the client both to build a relationship with the therapist and to seek in-
the-moment intervention in crisis and non-crisis situations (Linehan, 1993a,
1993b; Miller et al., 2006). The telephone consultations should be brief and
focus on building awareness about what is happening in the moment. One
way to introduce the telephone consultation to adolescent clients is to invite
them to “test call” the therapist when they are not in crisis, just to get used to
the idea of reaching out for assistance and support (Miller et al., 2006).

Case study application:

At first, Anna rejected the idea of telephone consultations and did not

respond when I encouraged her to call. While reviewing her behavior chain
at one of our sessions, I again reminded her that she could have tried a tele-
phone consultation with me, as a method of intervention, and explored her
reluctance to reach out to others for support. Then, one day, several weeks
later I received a page from Anna, who said she was feeling upset and did
not know why. She told me that she felt “unsafe” but could not identify any
triggering events or memories; she told me that the feeling had just come out
of nowhere. I validated Anna’s effort to reach out for support rather than

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dealing with these feelings alone, as she had typically done. Instead of re-
sponding directly to my questions, Anna said, “I’m afraid of what I might do.”
I validated her fear, and we talked about the part of her that felt out of her
control. Then I highlighted the dialectic. I told Anna that while part of her
feels out of control because she is not certain whether she can manage her
urges, another part of her feels somewhat in control because she initiated a
telephone consultation. This dialectic seemed powerful to her, and she said,
“You’re right. I’m not totally out of control.” I told her, “It sounds like you can
separate out the emotion that feels overwhelming at the moment, because
part of you is not out of control.” Anna then talked about having some con-
flicts with peers, feeling lonely, and like she did not fit in. She agreed to try
a few distress tolerance skills before her bedtime and told me she could stay
safe and go to bed. I assured her that if the techniques did not work, or if she
needed more support, she could call back.

When Anna came for her next therapy session, she did not bring up the tele-

phone consultation but instead proceeded to discuss other current life events.
The emotional storm seemed to have passed, and Anna had made it through
unscathed. Our telephone consultation dialogue had given me an important
window into Anna’s struggle with her self-injury urges and thought processes
in the very moment. In subsequent sessions, we worked on managing Anna’s
feelings of being out of control, so that she could develop means other than
self-injurious behaviors to gain a sense of control. She developed an under-
standing that, although intense experiences of emotions had caused her to
feel out of control, she had the ability to manage those feelings until they
passed. Control became an important theme, and we discussed ways in which
Anna could increase her sense of empowerment. For example, Anna felt little
control at home; thus, in family therapy, she and her parents listed family
rules and discussed which ones might be subject to negotiation. In one nego-
tiation, Anna gained permission to bring her pet gerbils out of the basement
and to keep them in her room. Her parents did not realize that, by confining
the gerbils within the basement, they had upset Anna so much. Renegotiat-
ing family rules with her parents proved a very positive experience for Anna.
It helped her voice unexpressed needs and feelings and sense that she had
more control over her environment. The therapeutic process, however, took a
lot of time because the parents had difficulty in changing their ingrained and
invalidating patterns of behavior.

Support is Essential

Working with self-injurious, suicidal adolescents can be extremely taxing.

It is important that both client and therapist build and access internal and

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external supports. There is a high risk of burnout for those professionals who
work with borderline clients, as well as a risk of becoming overly reactive
(hot and cold) to the borderline’s tendencies to test limits, push away, and
pull towards. Kreisman and Straus (1991) discuss this push-pull phenomenon
in a popular book entitled, I Hate You, Don’t Leave Me: Understanding the
Borderline Personality. Oftentimes the self-injurious client is overwhelmed
internally with intense emotions, which impact the therapeutic process. A col-
league once likened the process of doing therapy with the borderline client to
setting up a tent in the middle of a hurricane (the hurricane being the client’s
constant whirlwind of intense, inner emotions). The frequent challenges of
working with the self-injurious, borderline adolescent serve only to under-
score the need for clinicians to practice mindfulness, adopt a nonjudgmental
attitude, tolerate the ups and downs of the client’s emotions and behaviors,
and develop strong personal and professional support networks.

Conclusion

Core Gestalt theoretical ideas overlap with a select group of DBT principles:

awareness, mindfulness, sensory body experience, emotion regulation, accep-
tance, and client/therapist relationship as an agent of change. These princi-
ples can be integrated to create a holistic and effective approach with related
interventions for treating self-injurious adolescents. Gestalt therapists can
use these integrated interventions as “awareness tools,” through increased
awareness of themselves and their contact processes, and through improved
self-regulation skills, in order to promote the developmental process and
encourage maximum growth of the client. It is hoped that this integrated
approach will serve as an effective treatment model that facilitates healing
within both the self-injurious teen and her relationships.

Lynn Williams, Ph.D.
[e-mail]

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