The Four Agreements (Don Miguel Ruiz)

Attention is the ability we have to discriminate and to focus only on that which we want to perceive. 

As children, we didn't have the opportunity to choose our beliefs, but we agreed with the information that was passed to us from the dream of the planet via other humans. The only way to store information is by agreement. The outside dream may hook our attention, but if we don't agree, we don't store that information. As soon as we agree, we believe it, and this is called faith.

The reward feels good, and we keep doing what others want us to do in order to get the reward. With that fear of being punished and that fear of not getting the reward, we start pretending to be what we are not, just to please others, just to be good enough for someone else...We pretend to be what we are not because we are afraid of being rejected. 

The domestication is so strong that at a certain point in our lives we no longer need anyone to domesticate us...We punish ourselves when we don't follow the rules according to our belief system; we reward ourselves when we are the "Good boy" or "Good girl."

The inner judge uses what is in our Book of Law to judge everything we do and don't do, everything we think and don't think, and everything we feel and don't feel. Everything lives under the tyranny of this Judge.

Whatever goes against the Book of Law will make you feel a funny sensation in your solar plexus, and it's called fear...

That is why we need a great deal of courage to challenge our own beliefs. Because even if we know we didn't choose all these beliefs, it is also true that we agreed to all of them. The agreement is so strong that even if we understand the concept of it not being true, we feel the blame, the guilt, and the shame that occur if we go against these rules.

In your whole life nobody has ever abused you more than you have abused yourself. And the limit of your self-abuse is exactly the limit that you will tolerate from someone else. If someone abuses you a little more than you abuse yourself, you will probably walk away from that person. But if someone abuses you a little less than you abuse yourself, you will probably stay in the relationship and tolerate it endlessly. 

If you abuse yourself very badly, you can even tolerate someone who beats you up, humiliates you, and treats you like dirt. Why? Because in your belief system you say, "I deserve it. This person is doing me a favor by being with me. I'm not worthy of love and respect. I'm not good enough."

If you want to live a life of joy and fulfillment, you have to find the courage to break those agreements that are fear-based and claim your personal power. 

* * * * * 

The First Agreement: Be Impeccable with Your Word

Impeccability means "without sin."

A sin is anything you do which goes against yourself...Being impeccable is not going against yourself. When you are impeccable, you take responsibility for your actions, but you do not judge or blame yourself. 

We talk to ourselves constantly and most of the time we say things like, "Oh, I look fat, I look ugly. I'm getting old, I'm losing my hair. I'm stupid, I never understand anything. I will never be good enough, and I'm never going to be perfect." 

How much you love yourself and how you feel about yourself are directly proportionate to the quality and integrity of your word. When you are impeccable with your word, you feel good; you feel happy and at peace. 

Tell yourself how much you love yourself. Use the word to break all those teeny, tiny agreements that make you suffer.

The Second Agreement: Don't Take Anything Personally

[I]f I see you on the street and say, "Hey, you are so stupid," without knowing you, it's not about you; it's about me.

It is not important to me what you think about me, and I don't take what you think personally. I don't take it personally when people say, "Miguel, you are the best," and I also don't take it personally when they say, "Miguel, you are the worst." I know that when you are happy you will tell me, "Miguel, you are such an angel!" But, when you are mad at me you will say, "Oh, Miguel, you are such a devil!"

If you live without fear, if you love, there is no place for any of those emotions. If you don't feel any of those emotions, it is logical that you will feel good. When you feel good, everything around you is good. When everything around you is great, everything makes you happy. You are loving everything that is around you, because you are loving yourself. Because you like the way you are. Because you are content with you. 

The Third Agreement: Don't Make Assumptions

All the sadness and drama you have lived in your life was rooted in making assumptions and taking things personally. 

The way to keep yourself from making assumptions is to ask questions. Make sure the communication is clear. If you don't understand, ask. 

The Fourth Agreement: Always Do Your Best

Under any circumstance, always do your best, no more and no less. But keep in mind that your best is never going to be the same from one moment to the next. 

Breaking Old Agreements

The real you is still a little child who never grew up. Sometimes that little child comes out when you are having fun or playing, when you feel happy, when you are painting, or writing poetry, or playing the piano, or expressing yourself in some way. These are the happiest moments of your life -- when the real you comes out, when you don't care about the past and you don't worry about the future. 

But there is something that changes all that: We call them responsibilities. The Judge says, "Wait a second, you are responsible, you have things to do, you have to work, you have to go to school, you have to earn a living." All these responsibilities come to mind. Our face changes and becomes serious again. If you watch children when they are playing adults, you will see their little faces change. "Let's pretend I'm a lawyer," and right away their faces change; their adult face takes over...

The freedom we are looking for is the freedom to be ourselves, to express ourselves. But if we look at our lives we will see that most of the time we do things just to please others, just to be accepted by others, rather than living our lives to please ourselves. That is what has happened to our freedom. And we see in our society and all the societies around the world, that for every thousand people, nine hundred and ninety-nine are completely domesticated.

The worst part is that most of us are not even aware that we are not free. There is something inside that whispers to us that we are not free, but we do not understand what it is, and why we are not free...

From the Toltec point of view, all humans who are domesticated are sick. They are sick because there is a parasite that controls the mind and controls the brain. The food for the parasite is the negative emotions that come from fear...

If we want to be free, we have to destroy the parasite. One solution is to attack the parasite head by head, which means we face each of our fears, one by one. This is a slow process, but it works...

A second approach is to stop feeding the parasite. If we don't give the parasite any food, we skill the parasite by starvation. To do this we have to gain control of our emotions, we have to refrain from fueling the emotions that come from fear...

A third solution is called the initiation of the dead...

All of these old agreements which rule our dream of life are the result of repeating them over and over again. Therefore, to adopt The Four Agreements, you need to put repetition in action. Practicing the new agreements in your life is how your best becomes better. Repetition makes the master.

Heaven on Earth

Using your imagination and your new eyes of perception, I want you to see yourself living a new life, a new dream, a life where you don't need to justify your existence and you are free to be who you really are...

Imagine living without the fear of loving and not being loved. You are no longer afraid to be rejected, and you don't have the need to be accepted. You can say "I love you" with no shame or justification. You can walk in the world with your heart completely open, and not be afraid to be hurt...

The world is very beautiful and very wonderful. Life can be very easy when love is your way of life. You can be loving all the time. This is your choice. You may not have a reason to love, but you can love because to love makes you so happy. Love in action only produces happiness. Love will give you inner peace...

But there is really no reason to suffer. The only reason to suffer is because you choose to suffer... The same is true for happiness. The only reason you are happy is because you choose to be happy.

Schema Therapy (Rafaeli, Bernstein, Young)

A Taxonomy of Maladaptive Schemas

Domain I: Disconnection and Rejection. These schemas involve violations of the basical universal need for security, safety, stability, nurturance, empathy, sharing of feelings, acceptance, and respect. These schemas often develop when the early family environment is detached, withholding, cold, rejecting, violent, unpredictable, or abusive.

1. Abandonment/Instability. The perception that others, especially those from whom we expect support and connection, are unstable and/or unreliable in providing these.  
2. Mistrust/Abuse. The expectation that others will hurt, abuse, humiliate, cheat, lie, manipulate, or take advantage of them. Often involves the perception that the harm is intention. 
3. Emotional Deprivation. The expectation that one's desire for a normal degree of emotional support will not be adequately met by others. 
4. Defectiveness/Shame. The feeling that one is fundamentally defective, bad, unwanted, inferior, or invalid in important ways, or that one would be unlovable to significant others if they could see the real self. 
5. Social Isolation/Alienation. The feeling that one is isolated from the rest of the world, esp. the world outside the family. These people feel different than others, not part of any group. 

Domain II: Impaired Autonomy and Performance. These schemas involve violations of the basic universal needs for autonomy and competence, which lead to expectations about oneself and the environment that interfere with one's perceived ability to separate, survive, function independently, and perform successfully. These schemas often develop when the family of origin is enmeshed, undermining the child's confidence, overprotective, or failing to reinforce the child for performing competently outside the family. 

1. Dependence/Incompetence. The belief that one is unable to handle one's everyday responsibilities in a competent manner. 
2. Vulnerability to Harm or Illness. The exaggerated fear that catastrophe is imminent, that it will strike at any time, and that one will be unable to prevent it. 
3. Enmeshment/Undeveloped Self. Excessive emotional involvement and closeness with one or more significant others at the expense of full individuality or normal social development. Often involves the belief that at least one of the enmeshed individuals cannot survive or be happy without the constant support of the other. 
4. Failure. The belief that one has failed, will inevitably fail, or is fundamentally inadequate relative to one's peers, in areas of achievement. 

Domain III: Impaired Limits. These schemas are related to deficiencies in internal limits, responsibility towards others, or long-term goal-orientation. These schemas often lead to difficulties respecting the rights or others, cooperating with them, making commitments. These schemas often emerge when family of origin is permissive, overindulgent, has a sense of superiority. 

1. Entitlement/Grandiosity. The belief that one is superior to other people, entitled to special rights, not bound by the rules of reciprocity. 
2. Insufficient Self-Control/Self-Discipline. Pervasive difficulty or refusal to exercise sufficient self-control and frustration tolerance to achieve one's personal goals, or to restrain the excessive expression of one's emotions and impulses. 

Domain IV: Other-Directedness. These schemas are related to deficits in the fulfillment of the basic universal need for self-directness. Such deficits lead to an excessive focus on the desires, feelings, and responses of others, at the expense of one's own needs. This focus is driven by the need to gain love and approval, maintain a sense of connection or belonging, or avoid retaliation. These schemas usually involve a suppression or lack of awareness regarding one's own emotions, needs, or wishes, and lead to difficulties in assertion or self-determination.

1. Subjugation. An excessive degree of relinquishing control to others because one feels coerced to do so to avoid anger, retaliation, or abandonment.
2. Self-Sacrifice. An excessive focus on voluntarily meeting the needs of others, at the expense of one's own gratification. 
3. Approval-Seeking/Recognition-Seeking. An excessive emphasis on gaining approval, recognition, or attention from other people, or on fitting in, at the expense of developing a secure and true sense of self. 

Domain V: Overvigilance and Inhibition. These schemas are related to violations of the basic universal need for spontaneity and playfulness. These violations may result in an excessive emphasis on suppressing one's spontaneous feelings, impulses, or choices. They also may result in a perpetual focus on meeting rigid, internalized rules and expectations about performance and ethical behavior, often at the expense of happiness, self-expression, relaxation, close relationships, or health. Family of origin is often grim, demanding, punitive. 

1. Negativity/Pessimism. A pervasive, lifelong focus on the negative aspects of life, exaggerated expectation that things will eventually go seriously wrong.
2. Emotional Inhibition. Excessive inhibition of spontaneous action, feeling, or communication, usually to avoid disapproval by others, feelings of shame, or losing control of one's impulses.
3. Unrelenting Standards/Hypercriticalness. Underlying belief that one must strive to meet very high internalized standards of behavior and performance, usually to avoid criticism.
4. Punitiveness. The belief that people (including oneself) should be harshly punished for making mistakes. Involves the tendency to be angry, intolerant, punitive, and impatient with any person who does not meet one's expectations or standards.

Coping Styles and Responses

We tend to focus on information that is consistent with our schemas and ignored that which is inconsistent. We also tend to act in ways that perpetuate our schemas. 

We tend to choose "high chemistry" partners who unconsciously activate and perpetuate these same schemas: a distant partner who reinforces an Emotional Deprivation schema, etc.

Surrender Responses. That is, giving in to one's schemas -- e.g., being drawn to those who mistreat you. This might temporarily make you feel safer. 

Avoidant Responses. That is, avoiding people or situations that trigger your schemas. 

Overcompensation Responses. That is, attempting to do the opposite of a schema. 

Schema modes

Mode = the predominant emotional state, schemas, and coping reactions that are active for an individual at a particular time. Modes are transient states, whereas schemas are stable characteristics or traits. 

Individuals with borderline personality or narcissistic personality experience quick, often intense fluctuation among various mood states, flipping among modes in response to external or internal triggers. 

Healthy people move between modes but retain a unified sense of self and can simultaneously experience blends of modes (or more than one mode at a time). When they shift between modes, the do so gradually and not abruptly. 

The Vulnerable Child Mode. When we're in this mode, we are like wounded children. We may appear sad, hopeless, anxious, overwhelmed, helpless. This is a remnant of the time when we were children needing the care of adults in order to survive but did not receive that care. This mode holds the most schemas. The therapist's goal is to help the patient to accept and experience the vulnerability rather than push it away. This is the healthiest mode to be in, as vulnerability is essential for the sake of ultimately healing the schemas and gaining the capacity for getting one's needs met. 

The Angry Child Mode. When we're in this mode, we feel and express anger in response to unmet core needs. This mode can be triggered by feelings of mistreatment, abandonment, or humiliation in patients whose early emotional needs were chronically frustrated or went unmet. 

The Impulsive Child Mode. When we're in this mode, we behave impulsively. Patients with this mode often grow up in families that lack firm and consistent limit setting. 

Maladaptive Coping Modes. The Detached Protector mode is a state of emotional avoidance; you might deny feelings and problems, be emotionally detached. The Compliant Surrender mode is a state of compliance. The Overcompensator mode refers to a number of specific emotional states, all of which involve overcompensatory forms of coping -- i.e., doing the opposite of schemas in an attempt to escape from the painful emotions associated with them. 

Internalized Parent Modes. These modes involve an internalized parental voice that criticizes or denigrates the patient (Punitive Parent) or places almost impossible demands on him/her (Demanding or Critical Parent). 

Healthy Modes: Healthy Adult and Contented Child. The Healthy Adult mode is the part of the self that is capable, strong, and well-functioning. Borderline patients have almost no Healthy Adult mode. When in the Contented Child mode, we might feel at peace because our core emotional needs are being met; we experience others as loving and appropriately protective. This latter mode represents the capacity to experience and express spontaneity, glee, and playful happiness. 

Two Fundamental Therapeutic Stances

The main goal of Schema Therapy is to help adults get their emotional needs met, even when these needs were not met in the past. To achieve this, the therapy relationship needs to be one in which the patient's needs are recognized, articulated, validated, and fulfilled. The most important fulfillment is of those needs that were not met by the patient's parents when they were children. This bounded fulfillment of needs is called limited reparenting. 

Limited Reparenting. If a patient has strong Abandonment and Mistrust/Abuse schemas, they will most benefit from a therapist's emphasis on constancy, reliability, honesty, and availability. A patient who has the schema of Unrelenting Standards or a strong Critical Parent mode will benefit the most from a therapist who is generalize with praise and acceptance. 

Through limited reparenting, the therapist supplies the patient with a partial antidote to needs that were not adequately met in childhood; this is similar to a corrective emotional experience. 

Schema therapists extend typical therapy boundaries by encouraging out-of-session contact, using judicious self-disclosure, and expressing genuine warmth and care. This is done to permit the relationship to become similar to a parental, caring relationship. With time, the warmth and caring the patient receives is internalized and becomes part of their Healthy Adult mode. The therapist must determine which needs can be met by the patient and which require reparenting. 

Empathic Confrontation. This is where the therapist confronts the patient on their maladaptive behaviors and cognitions in an empathic, non-judgmental way. One way to do this is to frame one's problems in terms of schemas and coping responses -- e.g., "When your boss criticizes you, there is a side of you, the Abused Child side, that feels he is being abused all over again, just like you were by your parents. It's no surprise that you become angry and turn the tables on your boss by going on the attack. When you were a child, fighting back was the only way that you could preserve your self-respect. However, when you get into a fight with your boss now, he doesn't see the side of you that feels abused or mistreated. He just sees the Angry Child side and feels attacked. As a result, you don't get what you need, which is empathy and understanding. That's what you want from your boss; it's what you really needed from your parents, too." 

Assessment

Schema therapist initially take 2-4 sessions to gather information through a variety of assessment methods. The goals are to learn about the dysfunctional life patterns, to identify early maladaptive schemas, to learn the developmental origins of the schemas. Examples: the focused life history interview, the employment of self-report inventories, and the use of self-monitoring. 

Guided imagery can be part of the assessment process. The patient closes their eyes and lets an image come to them. Patient then describes the image. The goal is to elicit core images, those connected with primary emotions like fear, rage, grief, that are linked to the patients' early maladaptive schemas and childhood memories. 

Another part of assessment includes attention to the therapy relationship.

The assessment phase concludes by educating the patient, giving them a written case conceptualization. The conceptualization describes the patient's symptoms, identifies schemas, etc. If the therapist concludes that the patient has Axis I symptoms, the therapist treats those first using conventional CBT techniques. 

Therapist Toolbox

Toolbox 1: Relational Techniques. The therapist establishes a caring, trusting relationship which allows the patient to undergo the corrective emotional experience of having their needs met in a sufficient, healthy, and adaptive way. The therapist also uses this relationship as a safe place for exploring interpersonal and behavioral cycles that are driven by the patient's schemas and modes. 

When a schema is triggered in a session (sometimes resulting in a "therapeutic rupture"), the therapist seizes the opportunity -- first, by acknowledging the rupture ("I notice you became very quiet in the last minute"). If the patient acknowledges their anger or disappointment, the therapist empathizes and takes responsibility for their contribution to the rupture. If the patient instead continues to withdraw, the therapist may say something like, "You say you're not angry at me, but it makes me wonder why not. Putting myself in your shoes, I can easily imagine getting pretty upset. What do you think will happen if you did get angry at me?" The therapist can also link that rupture to underlying schemas: e.g., "Do you remember having a similar feeling with other people in your life?" 

Toolbox 2: Cognitive Techniques. (1) Schema diaries -- the patient is asked to record one particular event each day and to note their automatic thoughts, feelings, and behaviors in response to the event. In time, the patient is taught to test the evidence for and against their schema-driven view. (2) Reframing/Reattribution. Reframing involves providing a different cognitive frame (or explanation) than the one automatically generated. Reattribution can be used to help create a healthier view of schemas and their origins -- e.g., the therapist helps the patient reattribute their current life problem to a schema, rather than seeing it as inherent to the patient. (3) Schema Flashcards. These provide guidance for reattributing difficult situations in daily life. These are written summaries of the healthy response to a schema trigger. (4) Schema Dialogues. At first, the patient plays the schema side, and the therapist plays the healthy side. Eventually, the patient takes on the healthy side and is asked to counter the schema's arguments to come up with healthy responses. 

Toolbox 3: Emotion-Focused Techniques. Even if cognitive interventions are successful, the intense emotions attached to the schemas usually remain. (1) Role-Playing. Borrowed from Gestalt Therapy. The therapist asks the patient to play various roles -- e.g., different sides of himself/herself -- and to switch back and forth between roles. One technique is the two-chair method in which the patient keeps switching chairs. (2) Imagery. This can be so effective because patients often use avoidance; When therapists ask the patient to close their eyes and allow a scene from childhood to emerge spontaneously, they bypass the patient's coping modes. The images that emerge are usually connected to painful events. Research shows that schemas are easiest to change when cognitions are "hot."

Toolbox 4: Behavioral Pattern-Breaking. (1) Use of schema flashcards focused on alternative healthy behaviors. (2) Rehearsing a behavior in imagery or role-play. (3) Assigning behavioral homework. (3) Self-rewards.

Mode Dialogues and Imagery

Therapists ask patients to play different sides of themselves (i.e., different modes), switching chairs as they assume the role of different modes. 

Imagery in mode work. The therapist begins by asking the patient to close their eyes and imagine a scene from the present that is bothering them. The therapist then asks the patient to let go off the feeling while maintaining the feeling associated with it and to travel back to childhood and allow another image to emerge that has the same or a similar feeling. This new image usually shares schemas with the one from the present, enabling the patient to understand the way in which these themes from the past play themselves out in present life. The therapist then asks permission to enter into the image to provide for some of what the child needed, thus allowing direct reparenting. 

Borderline Personalities

Individuals with BPD often alternate abruptly and with great intensity between extreme emotional and motivational states: of anger or self-loathing, of idealization or devaluation, of intense feeling and numb emptiness. Schema Therapy sees these fluctuations as shifts among a relatively fixed set of schema modes. Most prominent BPD schema modes: the Detached Protector mode, the Abandoned/Abused Child mode, the Angry/Impulsive Child mode, the Punitive Parent mode, the Healthy Adult mode (usually very weakened). The Abandoned/Abused Child mode contains the memories, feelings, etc. of the patient as a young child, when the abuse, invalidation, etc. were most pronounced. 

The therapuetic goal is to strengthen the Healthy Adult mode so that it can in turn nurture the Abandoned/Abused Child mode, empathize but place limits on the Angry/Impulsive Child mode, and fight the Punitive Parent voice. Before any of this happens, the patient must allow the Detached Protector mode to step aside. 

Narcissists 

As a child, the narcissist learned to overcompensate for his schemas by developing a Self-aggrandizer mode, a side that feels superior. However, there remains a Lonely Child who feels empty and lonely. The key to therapeutic success is making contact with the Lonely Child. 

The therapist must empathically confront the Impulsive or Spoiled Child, the side that wants immediate gratification and has trouble tolerating frustration. Schema dialogue: the therapist asks the patient to play the side that believes it is "good to always get what you want when you want it." The therapist plays the healthy side, challenging the patient's beliefs. In essence, the therapist is arguing that if you always get what you want, you remain a child, unable to handle disappointments or frustrations, to pursue goals or plans, to get the rewards and privileges that come with being an adult. "Where has it gotten you to let a Spoiled Child run your life?" Many of these patients were given everything they wanted as children. 

Schema Therapy is also being used to treat individuals with Antisocial Personality Disorder. 

How to Be a Better Child Therapist

Positive Emotions. Children are always seeking good feelings. Therapists would do well to pay attention to a child's positive emotions.

Bad Feelings. Persistent emotional and behavioral problems in childhood are caused by painful emotions that remain active in the mind of the child. Most children in therapy have become discouraged, have come to believe that they will always have these bad feelings. The longer they remain in situations that evoke these bad feelings (e.g., schools in which they are failing), the more likely they are to seek relief in avoidant or self-destructive ways. Thus hope is an essential mechanism of therapeutic change.

Therapy often fails because the therapist cannot change the parents' perception and understanding of the child or a child's view of himself/herself.

The goal of therapy is to get children unstuck from bad feelings, from pessimistic expectations, and from pathogenic interactions.

Interest. As therapists (and as parents), our enthusiastic interest in a child's interests is the surest way to engage a child in meaningful dialogue or interaction and a first principle of strengthening family relationships. Question to ask parents during initial consultation: "What are your child's interests? What does he or she like to do?" This is how to begin a conversation with a child. Barish often spends almost all of the first session finding out about the child's interests.

Empathy. "Empathy is our therapeutic GPS. Empathy informs us when we have taken a wrong turn or subtly gone off course." Each expression of a therapist's empathy -- in any form -- arrests the spread of potentially malignant psychological events in the mind of the child. Empathy is a basic emotional need: "A child's confidence expectation of an empathic response -- that her feelings will be acknowledged and understood -- promotes a different orientation toward life and human relationships, an orientation characterized by openness and resilience." "Empathy helps make bad feelings tolerable. When children and adolescents feel heard and understood, they become, even if just for that moment, less absorbed in defiant thoughts and argument, and therefore more open to listening to us. Empathy allows a child to have her feelings without urgently needing to get rid of them, a core component of emotional regulation."

Children are able to regulate their emotions when they are confident that their feelings will be heard and understood, that problems can be solved, and that bad feelings, however painful, will not last forever. 

The best way to help children learn to regulate their emotions is to talk with them about their feelings. Parents should set aside time every day for emotional dialogue -- this is a time for listening, for accepting and validating a child's feelings. 

Play. Interactive play, beginning in infancy and continuing throughout childhood, is to children's social development what talking with children is to their vocabulary development and what exercise is to their physical development. All mammals play; it's a way to practice predatory skills, survival skills, social skills. Barish's work with children is usually a mixture of play and talk. "I offer all children an opportunity to play and then make an ongoing decision about how much play or how much talk will be a part of the therapy." 

Encouragement is essential. We must make not of every improvement, not every mistake. Working with children with problems: draw a large, blank rectangle; in the center of the rectangle, write the child's strengths; in the corner of the picture, draw her difficulties. 

Sleep. Important to ask about. 

Helping Others. Helping others is a source of meaning in life and of authentic self-esteem. 

Three principles to help families get unstuck: More frequent affirming interactions between parents and children; Repairing moments of criticism, anger, and misunderstanding; and Engaging children in proactive solutions to family problems.

• A first recommendation for strengthening family relationships is to set aside time every day to take a proactive interest in their children's interests and to play with their children. 

BPD: Loving Someone with Borderline Personality Disorder

Linehan reclassified BDPD into five areas of dysregulation:

1. Emotions. They have fast emotions -- come up quickly and change quickly. They have extreme emotions -- they are typically very, very intense. 
2. Relationship problems. Relationships are the most important thing in the world to them.
3. Impulsive. Impulsive behavior often makes them feel better, gets rid of certain emotions. They lose their judgment when emotions are high. 
4. Self-Dysregulation. Don't have a sense of what they like, what their values are, who they are. This is a byproduct of extreme emotionality, as they have trouble paying attention to their internal experiences and reactions to situations. It's like trying to read a road sign in the middle of a hurricane. 
5. Cognitive dysregulation. Difficulty controlling attention b/c emotions interfere with anyone's ability to pay attention. 

Causes: 

Biosocial Theory. Innate, biological vulnerability to emotions; and invalidating environments. As babies, people with BPD had an extreme response to getting tickled on the nose with feathers. Intensity of emotions is out of proportion -- emotional reactivity. It takes them longer to return to baseline.

Invalidating environment = an environment where the responses of the child are pervasively treated as inaccurate, unrealistic, trivial, or pathological. E.g., -- 

• Child doesn't like green beans. "Of course you like green beans. Everyone likes green beans."
• Child gets 98 on test. "Why didn't you get 100? I know you could have gotten 100."
• Child is hungry. "You're not hungry. You just ate."
• Child comes home crying after a fright with a friend. "You didn't need him as a friend anyway."

"Parents can contribute to an invalidating environment without being awful, abusive, insensitive people and without having anything but the best intentions for their child." 

* * * * *

Validation

Validation authenticates some aspect of the experience of another. It is finding one (sometimes very small) piece of a behavior that is authentically understandable to you and communicating to the other person that it is understandable. You don't even have to agree with them. 

People with BPD often have self-constructs of being out of control, having a lot of emotional pain, not being able to tolerate emotional pain, not being able to do things that others can do, not having a sense of who they are. So if your loved one has an identity that includes thinking she is worthless and undeserving of love and you are constantly telling her that she is wrong, that she is not worthless, etc., she will become more emotional around you and may well turn to her relationship with the violence drug addict who actually treats her like she's not worth anything and sometimes tells her outright she has no value. 

If your loved one believes she's worthless, and you say, "You're not worthless," you are arguing against her self-constructs. She will likely get more upset. Using validation, you would say, "Look, I know you see yourself as worthless. the fact is, you have done some things that have made you feel that way, and I know that your mistakes in life have made you feel bad about yourself. This is what I know about you, though...." 

Six levels of validation:

1. Stay Awake. This means paying attention and asking objective, probing questions -- basically showing that you're paying attention to them. Lean forward, nod your head.
2. Accurate Reflection. Communicate that you've heard the person accurately. You can repeat verbatim. Better to change the wording around so that they realize you get the gist of what they're saying. 
3. Stating the Unarticulated. Or mind reading. Requires that you create a little hypothesis about what the person is not telling you. Best to present it in question form. "You must really be beating up on yourself for doing something you had sworn not to do again, huh?"
4. Validating in Terms of Personal History or Biology. This is understanding one's action in the context of her entire life history. E.g., someone whose home burned down when she was five, her family lost everything. As an adult, she now becomes anxious during thunder storms. "I really understand why you want to hide in closes during storms. Your house burned down in a storm. It makes perfect sense that seeing lightning causes you to get really anxious. It's a part of your personal history." 
5. Normalizing. This communicates that others (without BPD) would have the same response. People with BPD feel they're different. When you normalize, you communicate that what's happening to them is the experience of being human, that anyone in the same situation would feel the same way. "We all have moments when we feel that way." "Of course you think that; anyone would in your situation." "I would feel that way you." 
6. Radical Genuineness. We often treat clients like they are more fragile than they really are. When you're radically genuine, you do not "fragilize," condescend, or talk down to the person you're trying to validate. This type of validation is talking to your loved one like you would anyone else.

* * * * *

Five Steps to Respond Effectively to Borderline Behavior

1. Regulate your own emotions.
2. Validate (do this at every step).
3. Ask/assess.
4. Brainstorm/troubleshoot.
5. Get information on your role (if any) and what you can plan on hearing about the outcome. 

Step #1: Regulate your own emotions

• Pause -- take a breath and notice your physical sensations. Label them as the emotion you are experiencing. ("My heart is pounding, I have a pain in my gut... The emotion I'm feeling is anger.")
• Pay attention to your body posture -- unclench your hands, relax the muscles on your face, make sure your other muscles are not tensed.
• Half-smile -- send calming messages to your brain. 
• Validate and cheerlead yourself -- ("My emotions are understandable given what is going on."

If these steps don't work, do the opposite. Anger -- disengage, walk away, hang up, don't email; then practice kindness. Sadness -- go for a walk, play tennis, do pleasant events not related to your loved one.

Step #2: Validate

Step #3: Ask/Assess

• Specifically but gently ask: "How would you like me to help? Do you want me to listen, give advice, or help you figure out what to do?"
• If the answer is no, just listen.
• If the person wants your input, asses what is going on: What happened? When did it start? What does your loved one see as the problem? What would she like to be the outcome?

Step #4: Brainstorm/Troubleshoot

• Generate a list of solutions with her help. 
• Collaborate with her to select an option.
• Anticipate what could get in the way of your loved one carrying out the plan.

Step #5: Get information on your role and what you can plan on hearing about the outcome

• Are there things that you need to do to help/support her carry out the plan?
• Request a check-in/follow-up if it's important to you. Tell her you're interested in knowing what happened and ask to be updated. This is very validating for her. 

* * * * * 

Communicating a Limit

• Tell her that you are going to end the conversation if _____ doesn't happen. 
• Give her a chance to modify her behavior. 
• Make sure you "own" that you are ending the interaction because of your reactions and what you want from the interaction -- e..g., "I know this is painful for you, but it's what I need to be able to stay in our relationship."

Use four-way pros-and-cons analysis to make decisions about communicating that a limit has been crossed. 

* * * * * 

Practicing Acceptance and Self-Compassion

"We are often told that we cannot change other people. As a behaviorist, I believe that we have some capacity to change others by changing our reactions to them."

We must accept reality every moment. We need to accept: (1) Our loved one as she is in this moment, (2) Our reactions to our loved one as she is in this moment, (3) The situation at hand.

How to practice acceptance in the heat of the moment with your loved one:

1. Determine what you are not accepting. Ask yourself, what is making me miserable?
2. State out loud: "I accept..."
3. Pay attention to your body posture. Make sure you have an accepting posture: hands not clenched, facial muscles relaxed.

You can practice acceptance and emotional regulation by developing compassion.

How to practice compassion with yourself:

1. Visualize yourself as joyous and accepting. See a half-smile on your face. Visualize yourself doing kind things. Picture yourself responding to situations with patience and skill.
2. Think of your positive qualities. What are some of your past acts of kindness? When were you accepting of someone even in the face of unpleasantness?
3. Make statements out loud that are compassionate, accepting, statements of yourself. E.g., "I have put myself in her shoes and realized how difficult it is for her to feel like she is losing everything even when she was yelling at me that she hated me." Find things about yourself to love and say them over and over again.

How to practice compassion to your loved one:

1. Visualize: picture your loved one being joyous and unburdened. What does this look like?
2. Think of positive qualities of your loved one and kind, compassionate things that she has done in her life. 
3. Make statements out loud that are compassionate, accepting statements of your loved one. 

Self-care as compassion:

• Take care of your physical self.
• Soothe your senses.

Cheerlead yourself:

• Think what you would say if a friend called and told you of a situation that was similar to yours.
• List three things that you would say to cheerlead your friend. 
• Repeat those three things to yourself each day until they become statements that you can say automatically. 

* * * * * 

BPD: Stop Walking on Eggshells

People with BPD feel the same emotions as others and do many of the things that others do, but they (a) feel things more intensely, (b) act in ways that seem more extreme, (c) have difficulty regulating their emotions and behavior.

DSM-IV definition of personality disorder:

• an enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual's culture
• pervasive and inflexible (unlikely to change)
• stable over time
• leads to distress or impairment in interpersonal relationships

Criteria for BPD: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: [I'm listing the ones relevant in my situation]

• Frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense personal relationships characterized by alternating between extremes of idealization and devaluation.
• Identity disturbance: Markedly and persistently unstable self-image or sense of self.
• Affective instability do to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
• Inappropriate, intense anger or difficulty controlling anger. 

When a caring person does something that a BP interprets as a sign that they're about to leave, the BP panics and reacts. They may burst into a rage or beg the loved one to stay. When your BP becomes upset, think about what happened that might have triggered fears of abandonment.

BPs look to others to provide things they find difficult to provide for themselves -- e.g., self-esteem, approval, a sense of identity. Most of all, they are searching for a nurturing caregiver whose never-ending love and compassion will fill the black hole of emptiness and despair inside them. 

At the same time, BPs have such low self-esteem that they don't understand why anyone would want to be with them. They are hypervigilant, looking for any cues that might reveal that the person they care about doesn't really love them and is about to desert them. 

A BP's current opinion of someone is often based on their last interaction with them -- like someone who lacks a short-term memory. 

BPs cannot handle inconsistencies and ambiguities, cannot reconcile one's good and bad qualities into a constant coherent understanding of the person. At any given moment, the person person is either good or evil, there is no in-between. Someone is either a friend or an enemy, a passionate lover or a platonic buddy. This is why BPs often don't like themselves -- they feel like failures if they don't attain perfection. 

BPs lack an essential sense of themselves, just as they lack a consistent sense of others. Feeling empty inside, they are dependent on others for cues about how to behave, what to think, and how to be. Being alone leaves them without a sense of who they are or with the feeling that they do not exist. 

Suicide seen as answer to overwhelming emotional pain. 

BPs need to control others because they feel out of control with themselves. Also, they're trying to make their own world more predicable and manageable. 

BPs are not intentionally manipulative; rather, this is a desperate attempt to cope with painful feelings or to get their needs met. They're acting impulsivity out of fear, loneliness, desperation, and hopelessness. 

High-functioning BPs appear normal to those outside the family.

Lots of projection -- denying one's own unpleasant traits, feelings by attributing them to others.

Non-BPs can feel brainwashed -- the BP isolates the non-BP, exposes them to constant messages, deprives them of sleep, abuses them, causes them to doubt what they know and feel. BP thinking: If there's just one thing wrong with me, I must be defective; I can't be defective, so if there's a problem, it must be someone else's fault.

Why the inconsistencies? Putting others in a no-win situation (e.g., you're too smothering, you don't care about me) allows them to self-validate when validation has been in short supply in their lives. Also, they have an inconsistent sense of self. In order to state their preferences, people must be able to clearly identify their feelings and beliefs, but some BPs have an inconsistent sense of self.

Sometimes BPs seem to be wanting you to "keep your distance a little closer." This is impossible. This behavior pattern results from two primary and conflicting fears: the fear of being abandoned and the fear of being engulfed or controlled by others. The urge to merge and the desire for independence cause them to look like a walking contradiction. Sometimes they seek closeness and nurturing and sometimes seem compelled to drive you away.

One you get too close, they feel engulfed or afraid of losing control. They don't know how to set healthy personal limits and genuine intimacy makes them feel vulnerable. They might be afraid that if you see the "real" them, you'll be repulsed and leave them. So they push you away, but the distance makes them feel alone.

* * * * *

5 tools to take back control of your life:

1. Take care of yourself -- find support, mindfulness
2. Uncover what keeps you feeling stuck
3. Communicate to be heard
4. Set limits with love
5. Reinforce the right behaviors

Making changes within yourself:

• Know who you are, act according to your values, communicate what you need and want to the people in your life
• Detach with love (from Al-Anon): I'm not responsible for her disease or recovery from it; I let go of my obsession with her behavior and begin to lead a happier, more manageable life. 
• I didn't cause it, I can't control it, I can't cure it.
• Understand the effects of intermittent reinforcement. This can lead to feelings of addiction (98-99). 
• To get unstuck, stop focusing on the BP and work on becoming more of your own person. Help others without rescuing. Express confidence in your family member's ability to start finding solutions to her problems. "I'm here if you need me, but your choices belong to you.
• Believe you don't deserve to be treated badly. 
• Have a firm sense of who you are apart from the BP. 

Set boundaries:

• Kahlil Gibran: Stand together yet not too near together: for...the oak tree and the cypress grow not in each other's shadow. Enmeshment is comparable to the oak tree and the cypress growing so close together that their branches and roots become entwined. 
• Set limits and learn to take care of your own needs and live your own life. 
• Paraphrasing and reflexive listening: Make I statements; Restate key points; Make neutral observations; Stay focused on your message; Simplify; Give positive feedback; Ask questions.
• Responding to attacks and manipulation: don't defend, don't deny, don't counterattack, don't withdraw.
• Defusing techniques: agree with part of the statement; agree with the possibility that your critic could be right; recognize that she has an opinion. 

Asserting your needs with confidence and clarity:

• Stop sponging, start reflecting. 
• Ways to reflect or mirror BPD behavior: breathe deeply; keep seeing shades of gray; separate your feelings from theirs.
• Acknowledge before disputing.
• Prepare for the discussion: be specific; communicate one limit at a time; begin with the easy stuff

The Little ACT Workbook

ACT is about "getting unstuck and learning new and, hopefully, more effective strategies to handle difficult thoughts, unpleasant emotions and physical sensations when they show up, so you can stay on track. By 'staying on track' we mean doing the things that matter to you in your life and behaving in a manner that's consistent with the kind of person you want to be -- rather than always being controlled by the thoughts, emotions and physical sensations you might experience in any given moment."

ACT is about:

• Waking Up -- that is, being "present in the 'here and now,' noticing the psychological traps and 'stories' that our minds tell us, which often hold us back in life."
• Loosening Up -- "actively and purposely responding to our thoughts, emotions and physical sensations in a more open and accepting way, without judgement and defence."
• Stepping Up -- "identifying and clarifying what really brings meaning and fulfillment into your life."

* * * * * 

What unwanted experiences do you try to eradicate? Emotions, thoughts, and physical sensations you'd like to get rid of. Strategies you use to accomplish this -- avoidance, taking your mind of it, etc.

Quicksand analogy: friend caught in quicksand; the only way to get free is to stop struggling. "Perhaps the key to experiencing unwanted emotions as manageable rather than overwhelming is, ironically, to allow ourselves to feel those emotions."

* * * * * 

Wake Up!

We need to turn off the autopilot. Rumination is thinking about past, worry is thinking about the future. 

"In order to 'wake up' we need to switch off the autopilot mode by using our awareness to deliberately focus on the present moment, with a non-judgemental, curious and flexible attitude. A skill that can help us to do this is mindfulness."

Thinking self vs. observer self. "YOU are bigger and more than your thoughts and feelings. Your observer self is the space from which you can stand and observe the stories that your thinking self is producing." Exercises 3.11, 3.12.

* * * * * 

Loosen Up!

Path analogy: your cycling along a path and reach a fork in the road; one path has no major obstacles, and you know where it goes; the other path is "overgrown, thick with brambles and full of potholes." Which path would you take if everything important to you lie along the second path?

Feeding your tiger analogy.

Acceptance = the willingness to be open "to our whole experience, including our unwanted thoughts, emotions and physical sensations." Ongoing awareness of our thoughts and feelings requires a non-judgemental focus on the present moment." "If, in any given moment or context, our experience tells us that trying to control, change or avoid our thoughts and feelings takes us away from the kind of life that we want to be living, then it follows that accepting and loosening up around these unwanted thoughts and feelings, just as they are, might be a more useful strategy."

The Transistor Radio. Imagine a radio with two dials. One dial measures the strength of your unwanted thoughts, emotions, and physical sensations. The other dial measures your willingness "to have and accept these experiences while you do things that move you towards living the kind of life that really matters to you." 

Willingness "is not about tolerating thoughts and feelings, increasing our willpower or like hanging on for dear life while riding a white-knuckle ride! Instead, willingness involves taking an accepting and curious stance towards our unwanted experiences [using defusion techniques], allowing these thoughts and feelings to come and go in the interests of continuing vigorously to pursue our values in life." 

Exercise 4.1

"Sometimes difficult thoughts do reflect a difficult reality; no amount of thought challenging is going to change this." 

Exercises 4.5, 4.6, 4.7, 4,8

* * * * * 

Step Up!

"Instead of being driven through life by our thoughts or emotions, we can instead choose what we want to do." "I'm having these really difficult thoughts, sensations and emotions, AND I'm willing to take them with me so that I can move towards the things that matter most to me in life." 

Exercises 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8.

The observer self can help you to realize your values (p. 203).

Make SMART goals. 

We're more likely to stick to our goals if we tell others about them. 

Behavioral, Social, and Emotional Assessment of Children and Adolescents (Whitcomb)

Whitcomb's underlying theoretical orientation: social cognitive theory. Social cognitive theory is based on the work of Albert Bandura. This theory holds that "behavior, environmental influences, and various personal factors (e.g., cognition, temperament, biology) all work together in an interactive manner and have the effect of acting as determinants of each other."

A broad-based assessment (aka a multimethod, multisource, multisetting assessment):

• Methods: direct observation, behavior rating scales, interviews, record review, sociometric assessment, self-report measures.
• Sources: child, parents, other family members, teachers, other school personnel, peer group, community-based informants.
• Settings: home, school, clinic, play, community.

* * * * *

Differential diagnosis involves two steps: (1) "making a binary decision as to whether the problem is considered normal or abnormal" and (2) deciding how to classify the problem specifically (e.g., conduct disorder versus oppositional defiant disorder).

Type I error (or false-positive error): when you classify someone as having a disorder that they in fact don't have. Type II error (false-negative error): when you classify someone as being normal when they in fact have a disorder.

Different classification systems: DSM-5, classification under special education law.

An alternative to classification: behavioral dimensions approach. "The paradigm used in the behavioral dimensions approach is rooted in empirical methods of measuring behavior and complex statistical procedures that allow for the identification of behavioral clusters, which refer to clusters of highly intercorrelated behaviors." Primarily developed by Thomas Achenbach and his colleagues.

The Achenbach System of Empirically Based Assessment (ASEBA).  ASEBA identifies two primary broad-band syndromes: internalizing problems (a.k.a. overcontrolled behavior) (e.g., anxiety, depression, somatic complaints, social withdrawal) and externalizing problems (a.k.a. undercontrolled behavior) (e.g., delinquent behavior, aggressive behavior, hyperactivity). ASEBA also identifies narrow-band syndromes: withdrawn, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior.

"The ASEBA is arguably the most sophisticated system of child behavior assessment tools currently available, and it is certainly the most extensively researched. These tools have become widely used by practitioners in school and clinical settings and by researchers."

One problem of conducting assessments using many sources and instruments is behavioral covariation.

Multiple gating: "through a series of assessment and decision steps (gates), a large population is sequentially narrowed down to a small population of individuals who are very likely to exhibit the behavioral syndromes in question across settings and over time." The first step (or gate) consists of screening a large population...

* * * * * 

Behavior Rating Scales

The advantage of behavior rating scales over checklists is that rating scales not only "allow the rater to indicate whether a specific symptom is present" but also "provide a means of estimating the degree to which a characteristic is present." Advantages of rating scales: (a) more inexpensive than direct behavioral observation, (b) they're "capable of providing data on low-frequency but important behaviors that might not be seen in a limited number of direct observation sessions," (c) a rating scale is "an objective assessment method that provides more reliable data than unstructured interviews or projective-expressive techniques," (d) they can be used to assess children "who cannot readily provide information about themselves," (e) they "capitalize on observations over a period of time in a child's" natural environment, (f) they "capitalize on the judgments and observations of persons who are highly familiar with the child or adolescent's behavior."

Problems with behavior rating scales: bias of response and error variance. Three types of response bias:

1. Halo effects ("rating a student in a positive or negative manner simply because they possess some other positive or negative characteristics not pertinent to the rated item").
2. Leniency or severity ("the tendency of some raters to have an overly generous or overly critical response set when rating all subjects").
3. Central tendency effectives ("the proclivity or raters to select midpoint ratings and to avoid endpoints of the scale such as 'never' and 'always'")

Types of error variance found with rating scales:

1. Source variance: different raters respond to statements/questions differently.
2. Setting variance: what works for child in one environment might not work in other environments. 
3. Temporal variance: behavior often changes over time, and a respondent's ratings might change over time. 
4. Instrument variance: different scales often measure different hypothetical constructs. 

Another problem with rating scales: respondents tend to give disproportionate weight to recent events.

ASEBA, BASC, and Conners "represent some of the best constructed and widely researched instruments currently available."

Best practices: (a) a great use of rating scales is to use them as screenings; children whose rating scale scores are 1 or more standard deviations above the mean should be considered for further evaluation; this narrows down the screening pool to 16 percent of population; (b) use the aggregation principles (i.e., obtain ratings from multiple sources in multiple settings); (c) assess progress during and after interventions.  

* * * * * 

Interviewing Techniques

It's important to observe the child during the interview, especially because children's "typically unsophisticated verbal mediation skills make it difficult for them to express directly their concerns, needs, and problems." A good interviewer is aware of the developmental stages. 

Interviews with elementary-aged children "may be enhanced by: (1) relying on familiar settings and activities during the interview; (2) allowing them to use manipulatives and drawings during the interview; (3) avoiding constant eye contact (which elementary-aged children are typically not used to); and (4) providing contextual cues (such as pictures, colors, and examples) with requests for language interaction." 

(1) Traditional or Unstructured Interviewing

This term "represents a broad range of clinical interviews that are relatively open-ended, less structured, and highly adaptable depending on the situation." 

Gathering background information from parents/teachers:

1. Medical History. Problems during pregnancy and delivery? Complications shortly after birth? Serious illnesses/high fevers or convulsions? Serious injuries or accidents? Serious illnesses in family history? Allergies or dietary problems? Current health problems or medications? Vision and hearing OK?
2. Developmental history. Ages for reaching developmental milestones: crawling, talking, walking, toilet-training. Developmental delays (communication, motor, cognitive, social)? Development in comparison with siblings or peers. 
3. Social/emotional functioning. Temperament as an infant/toddler? Quality of attachment to caregivers as infant/toddler? Quality of relationships with parents? Quality of relationships with siblings and peers? Discipline methods: what works best, who does he or she mind the best? Behavioral problems at home or in community? Number and quality of friendships with peers. Any traumatic/disturbing experiences? Any responsibilities or chores?
4. Educational progress. Initial adjustment to school? Academic progress: delayed, average, high-achieving? School grades and progress notes? Any school attendance problems? Behavioral problems at school? Quality of peer relations at school? Favorite subjects, classes, or teachers? Etracurricular activities?
5. Community involvement. Belong to any organizations or clubs (e.g., Boys and Girls Club)? Organized team sports? Religious background/participation? Relationships with etended family. 

Example of comprehensive formal developmental history interview: the Structured Developmental History form from the BASC-3. 

Interviewing the child. Four areas to observe: 

1. Physical characteristics. Unusual or inappropriate attire. Height and weight in comparison to same-age peers. Obvious physical difficulties. Direct signs of possible illness. Motor coordination. Tics (vocal, facial, motor). 
2. Overt behavioral characteristics. Activity level. Attention span. Interaction with environment. Distractibility. Impulsivity.
3. Social/emotional functioning. Range and appropriateness of affect. Mood state during interview. Reaction to praise. Reaction to frustration. Social skills with interviewer. Obvious anxiety or nervousnesss. Ease of separate from caregiver. 
4. Cognitive functioning. Communication skills. Overall intellectual competence, estimated. Intrapersonal insight/self-awareness. Logic of reasoning. Time and space orientation. Level of organization in activities. Apparent planning ability. 

Interviewing the child. General areas of questioning:

1. Intrapersonal functioning. Eating and sleeping habits. Feelings/attributions about self. Peculiar or bizarre experiences (e.g., hearing or seeing things). Emotional status (e.g., depressed, anxious, guilty, angry, happy). Clarity of thought/orientation to time and space. Insight into own thoughts and concerns. Defensiveness/blaming. Understanding of reason for interview. 
2. Family relationships. Quality of relationships with parents. Quality of relationships with siblings. Family routines, responsibilities, chores. Involvement with extended family members. Level of perceived support from family. Perceived conflicts within family. 
3. Peer relationships. Number of close friends. Preferred activities with friends. Perceived conflicts with peers. Social skills for initiating friendships. Reports of peer rejection and loneliness. 
4. School adjustment. Current grade, teacher, school subjects. General attitudes/feelings about school. Previous and current academic performance. Favorite or preferred subjects or teachers. Difficult or disliked subjects or teachers. Involvement in extracurricular activities. School attendance patterns. Perceived conflicts or problems at school. 
5. Community involvement. Involvement in clubs or youth organizations. Participation in community activities. Religious activities. Levels of mobility within community. Relationships with others in the community. 

(2) Behavioral Interviewing

The primary purpose of behavioral interviewing is to understand the functions of problem behavior. Examples: The Functional Assessment Checklist for Teachers and Staff, The Functional Assessment Checklist for Students. 

(3) Structured or Semistructured Diagnostic Interviewing

Most school-based practitioners will find that "the most complex and highly structured interview tools are not practical for day-to-day use. These tools require extensive training and time, and are more suited for settings such as teaching hospitals, and for purposes such as research." Examples: the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS), the Semistructured Clinical Interview for Children and Adolescents (SCICA).

* * * * *

Internalizing Problems

Observational technique used in the assessment of anxiety: Behavioral Avoidance Test (BAT) (subject observed as he/she approaches anxiety- or fear-provoking stimulus).

Kazdin "listed three general classes of behavioral codes that could be used for direct observational assessment of childhood depression":

1. Social activity: talking, playing a game, participating in a group activity.
2. Solitary behavior: playing a game alone, working on an academic task, listening and watching, straightening one's room, grooming.
3. Affect-related expression: smiling, frowning, arguing, complaining. 

The Anxiety Dimensional Observation Scale (Anx-DOS). 

Behavior rating scales should be used, but it should be noted that "many aspects of internalizing problems are not readily detectable to an external observer, even one who knows the child or adolescent relatively well." Parent reports tend to be more accurate for assessing externalizing problems, while child self-reports tend to be more accurate for assessing internalizing problems.

Self-reports should be used. Recommended: CDI, RCMAS, RCDS, RADS-2, MASC-2, TAIC,Interviewing should be done; see the Children's Depression Rating Scale (CDRS). Sociometric assessments "can screen effectively for internalizing problems in children."