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American

Journal of
Psychotherapy Official Journal of AAP Founded in 1939

Volume 69 Number 2 2015

Highlight

SPECIAL ISSUE
DIALECTICAL BEHAVIOR THERAPY:
EVOLUTION AND ADAPTATIONS IN THE 21ST
CENTURY

Dedicated to the Transtheoretical Practice and Research of Psychotherapy


VOLUME 69, NUMBER 2 American Journal of Psychotherapy 2015, pp. 91239
American Journal of Psychotherapy
Official Journal of the Association for the Advancement of Psychotherapy
Founded in 1939

EDITOR-IN-CHIEF
BRUCE J. SCHWARTZ

DEPUTY EDITOR
SCOTT WETZLER

ASSOCIATE EDITORS
SALVATORE LOMONACO
JERALD KAY
ALLAN TASMAN

EDITORIAL BOARD
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PAUL CRITS-CHRISTOPH PAUL L. WACHTEL
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Table of Contents
Incorporating The Journal of Psychotherapy Practice and Research

HIGHLIGHT
Special IssueDialectical Behavior Therapy: Evolution and
Adaptations in the 21st Century
EDITORIAL
Dialectical Behavior Therapy: Evolution and Adaptations in the 21st
Century 91
Alec L. Miller, Psy.D.
ORIGINAL ARTICLES
The Course and Evolution of Dialectical Behavior Therapy 97
Marsha M. Linehan, Ph.D., ABPP, Chelsey R. Wilks, M.S.
Transdiagnostic Applications of DBT for Adolescents and Adults 111
Lorie A. Ritschel, Ph.D., Noriel E. Lim, Ph.D.,
Lindsay M. Stewart, Ph.D.
Dialectical Behavior Therapy and Eating Disorders: The Use of
Contingency Management Procedures to Manage Dialectical
Dilemmas 129
Lucene Wisniewski, Ph.D., Denise D. Ben-Porath, Ph.D.
Radically Open-Dialectical Behavior Therapy for Disorders of
Over-Control: Signaling Matters 141
Thomas R. Lynch, Ph.D., FBPsS, Roelie J. Hempel, Ph.D.,
Christine Dunkley, DClinP
Treatment Acceptability Study of Walking The Middle Path, a New
DBT Skills Module for Adolescents and their Families 163
Jill Rathus, Ph.D., Bevin Campbell, Psy.D., Alec Miller, Psy.D.,
Heather Smith, Ph.D.
Dialectical Behavior Therapy for Suicidal Latina Adolescents:
Supplemental Dialectical Corollaries and Treatment Targets 179
Miguelina German, Ph.D., Heather L. Smith, Ph.D.,
Camila Rivera-Morales, M.A., Garnetta Gonzalez, B.A.,
Lauren A. Haliczer, M.A., Chloe Haaz, M.S.,
Alec L. Miller, Psy.D.
Mentalization and Dialectical Behavior Therapy 199
Charles R. Swenson, M.D., Lois W. Choi-Kain, M.D., M.Ed.
Towards the Development of an Effective Working Alliance: The
Application of DBT Validation and Stylistic Strategies in the
Adaptation of a Manualized Complex Trauma Group Treatment
Program for Adolescents in Long-Term Detention 219
Samuel J. Fasulo, Ph.D., Joanna M. Ball, Ph.D.,
Gregory J. Jurkovic, Ph.D., Alec L. Miller, Psy.D.

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EDITORIAL

Introduction to a Special Issue


Dialectical Behavior Therapy: Evolution
and Adaptations in the 21st Century

ALEC L. MILLER, Psy.D.


Born from the randomized controlled trial by Linehan and colleagues in
1991, dialectical behavior therapy (DBT) has become the gold standard for
treatment of individuals who are suicidal and have borderline personality
disorder. In this special issue, we begin with a historical review of DBT
provided by the treatment developer herself. We then introduce readers to
new, 21st century adaptations developed of this treatment modality. In this
issue we explore the use of DBT for suicidal adolescents with one paper
focusing on Latina teens and their parents, and one focused on the more
recently developed walking the middle path skills module. Other papers in
this issue include unique adaptations of DBT for eating disorders, and
disorders of over-control, as well as trauma in incarcerated male adolescents.
We also look at transdiagnostic applications of DBT and finally a comparison
of DBT with mentalization-based treatment.

Dialectical behavior therapy (DBT) was born in 1991 when Linehan


and her colleagues published the results of their first randomized con-
trolled trial demonstrating the treatments efficacy in reducing suicidal
behaviors and improving other outcomes among adult women diagnosed
with borderline personality disorder (Linehan, Armstrong, Suarez,
Allmon, & Heard, 1991). This was the first empirically supported treat-

Chief, Child and Adolescent Psychology, Director, Adolescent Depression and Suicide Program,
and Associate Director, Psychology Internship Training Program, Montefiore Medical Center/Albert
Einstein College of Medicine, Bronx, NY. Mailing address: Montefiore Medical Center, Department
of Psychiatry and Behavioral Sciences, 3340 Bainbridge Avenue, Bronx, NY 10467. e-mail:
aleclmiller@gmail.com
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

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AMERICAN JOURNAL OF PSYCHOTHERAPY

ment for this population. In 1993, Linehan published her DBT treatment
manual and skills-training manuals, which were used in her 1991 outcome
study (1993a; 1993b). The immediate impact of these works was profound,
and led to the development of numerous adaptations, which were first
highlighted in a special section that I co-edited with Jill Rathus 15 years
ago (Miller & Rathus, 2000). The adaptations described at the time
included DBT for use with adolescents, domestic violence, forensic set-
tings, substance abuse, and the treatment of elderly individuals with
depression and personality disorders (Miller & Rathus, 2000).
During the past 25 years and after the publication of in excess of 20
randomized trials conducted by more than 12 independent investigators,
DBT has become the gold-standard treatment for individuals who are
suicidal and diagnosed with borderline personality disorder. This treat-
ment continues to capture the attention of researchers, clinicians, and
consumers alike, largely due to backing by sound research, and because it
is a multimodal, principle-based treatment that conceptualizes emotional
dysregulation based upon the biosocial theory (Linehan, 1993a) that
engenders compassion among clinicians and others in the clients environ-
ments.
In this current special issue, we begin with a historical review of DBT
provided by the treatment developer herself, and we introduce readers to
new adaptations developed in the 21st century. In the first article entitled
The Course and Evolution of DBT, the authors describe how DBT was
developed through trial and error to apply standard behavior therapy to
highly suicidal individuals. They go on to further recount how the treat-
ment modularity and hierarchical structure has allowed for easy adaptation
and application to novel populations and settings. Linehans new skills
manual (Linehan, 2015) was developed in large part due to the varied
clinical needs of existing and novel clinical populations receiving DBT.
Linehan and Wilks highlight some future directions where DBT may
continue to evolve, including for use in schools (Mazza, Mazza, Miller,
Rathus, & Murphy, in press).
One of the major areas of adaptation within the field of DBT has been
with adolescents who are suicidal (Miller, Rathus, & Linehan, 2007;
Rathus & Miller, 2002; Rathus & Miller, 2015). After 20 years of promising
research by numerous investigators, Mehlum and colleagues (2014) re-
cently published the first randomized, controlled trial of DBT with suicidal
and self-harming adolescents. This special section contains three articles
highlighting clinical adaptations of DBT for youth. In their article, Treat-
ment acceptability study of walking the middle path, a new DBT skills
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Dialectical Behavior Therapy

module for adolescents and their families, Rathus, Campbell, Miller &
Smith provide a description and empirical evaluation of this uniquely
developed skills module for teens. Teens and families genuinely find these
new skills helpful.
In a related paper evaluating dialectical dilemmas, otherwise known as
polarizing behavioral patterns that can arise in family systems, German,
Smith, Rivera-Morales, Gonzalez, Haaz and Miller employ a mixed-
methods analysis to study these patterns among suicidal Latina adolescents
and their mothers. Corollaries of previously identified adolescentfamily
dilemmas are created that appear useful when working with Hispanic
families. Culturally informed secondary treatment targets are presented to
help treat the identified problematic behavioral patterns of old school vs.
new school parenting as well as over-controlling vs. under-controlling
parenting.
Fasulo, Ball, Jerkovic, and Miller, apply and adapt a DBT-informed,
trauma-focused treatment for male adolescents who are incarcerated in
juvenile justice settings. Not surprisingly, while the DBT principles are the
same regardless of gender, age, ethnicity, and diagnosis, the emphasis on
acceptance-oriented strategies, including rapport, radical genuiness, and
validation, is critical to the engagement of these young men. This paper
includes clinical vignettes that bring to life the exciting work conducted by
the first two authors.
Ritschel, Lim and Stewart (2015) present their paper describing the
transdiagnostic applications of DBT for adolescents and adults. They
highlight that beyond the treatment of borderline personality disorder and
suicidal behavior, DBT has been shown to be effective for those with
substance use disorders, eating disorders, PTSD, as well as adolescents (as
highlighted in the earlier papers). Clinicians will find this paper useful in
considering how the adaptations work across diagnostic groups, ages, and
settings.
Some of the leading experts in the treatment of eating disorders,
Wisniewski and Ben-Porath, present a paper not only reviewing the
application of DBT to eating disorders but also suggesting a novel use of
contingency management procedures to manage dialectical dilemmas in
this population. Specifically, the authors describe the highly problematic
dilemma of apparent compliance vs. active defiance and how to treat it
effectively.
Lynch, Hempel, and Dunkley present a unique application of DBT to
those with disorders of over control named Radically Open DBT. Such
disorders include anorexia nervosa, chronic depression, and obsessive-
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AMERICAN JOURNAL OF PSYCHOTHERAPY

compulsive personality disorder. Persons who suffer from over control


often experience social isolation, cognitive rigidity, risk aversion, and
inhibited emotional expression. In contrast to targeting emotional dysregu-
lation, this treatment targets over control. The paper highlights the com-
monalities and differences from standard DBT.
Finally, Swenson and Choi-Kahn compare aspects of DBT with another
evidence-based treatment for BPD, called mentalization-based treatment
(MBT; Bateman and Fonagy, 1999; 2001). MBT treatment developers
suggest mentalizing is the crucial ingredient in secure attachment and is
thus the focus of their treatment since individuals with BPD are thought to
be poor at mentalizing their own states, others states, and the relational
state. The authors, a DBT and an MBT expert, examine whether or not
mentalizing is already present in DBT practice, whether it would be
compatible with DBT conceptually and practically, and whether a focus on
mentalizing would be of use to DBT therapists and their patients.
I hope this special issue informs the AJP readership about the evolution
and adaptations of DBT in the 21st century and further stimulates clinical
research and practice of this treatment.

Acknowledgement: Special thanks to Elizabeth Courtney-Seidler, PhD, for her assistance on the
development of this Special Section.

REFERENCES
Bateman, A.W., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of
borderline personality disorder: a randomized controlled trial. American Journal of Psychiatry,
156, 1563-1569.
Bateman, A.W., & Fonagy, P. (2001). Treatment of borderline personality disorder with psychoana-
lytically oriented partial hospitalization: an 18-month follow-up. American Journal of Psychiatry,
158, 36-42.
Fasulo, SJ, Ball, JM, Jurkovic, GJ, Miller, AL. (2015). Adapting a manualized complex trauma
treatment program for incarcerated adolescents: Lessons learned regarding the application of
DBT acceptance-based strategies. American Journal of Psychotherapy.
German, M, Smith, HL, Rivera-Morales, C, Gonzalez, G, Haliczer, LA, Haaz, C, & Miller, AL. (2015).
Dialectical behavior therapy for suicidal Latina adolescents: Supplemental dialectical corollar-
ies and treatment targets. American Journal of Psychotherapy.
Hashim, R, Vadnais, M, & Miller, AL. (2013). Improving adherence in adolescent chronic kidney
disease: A DBT feasibility trial. Clinical Practice in Pediatric Psychology, 1-11.
Linehan, M.M. (1993a). Cognitive Behavioral Treatment of Borderline Personality Disorder. New York:
Guilford Press.
Linehan, M.M. (1993b). Skills Training Manual for Treating Borderline Personality Disorder. New
York: Guilford Press.
Linehan, MM, & Wilks, C. (2015). The course and evolution of DBT. American Journal of
Psychotherapy.
Lynch, TR, Hempel, RJ, Dunkley, C. (2015). Radically Open-Dialectical Behavior Therapy for
Disorders of Overcontrol: Remembering our Tribal Nature. American Journal of Psychotherapy.
Mazza, JJ, Dexter-Mazza, ET, Miller, AL, Rathus, JH & Murphy, H. (In press). DBT Skills Training

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Dialectical Behavior Therapy

for Emotional Problem Solving for Adolescents (DBT STEPS-A): Implementing DBT skills
training in schools. The Guilford Press, NY.
Mehlum, L, Tormoen, A, Ramberg, M, Haga, E, Diep, L, Laberg, S, Larsson, B, Stanley, B, Miller, AL,
Sund, A, Groholt, B. (2014). Dialectical behavior therapy for adolescents with recent and
repeated self-harming behavior-first randomized controlled trial. Journal of the American
Academy of Child and Adolescent Psychiatry, 53, 1082-1091.
Miller, AL, Rathus, JH, & Linehan, MM. (2007). Dialectical behavior therapy with suicidal adolescents.
The Guilford Press, NY.
Miller, AL, & Rathus, JH (2000). Dialectical behavior therapy: Adaptations and new applications.
Cognitive & Behavioral Practice, 7, 420-425.
Rathus, JH, Campbell, B, Miller, AL, & Smith, HL. (2015). Treatment acceptability study of walking
the middle path, A new DBT skills module for adolescents and families. American Journal of
Psychotherapy.
Rathus, JH, & Miller, AL. (2015). DBT Skills Training for Adolescents. The Guilford Press, NY.
Ritschel, LA, Lim, NE, & Stewart, LM. (2015). Transdiagnostic applications of DBT for adolescents
and adults. American Journal of Psychotherapy.
Swenson, CR, & Choi-Kahn, LW. (2015). Mentalization and Dialectical Behavior Therapy. American
Journal of Psychotherapy.
Wisniewski, L. & Ben-Porath, D. (2015). Dialectical Behavior Therapy and Eating Disorders: The Use
of Contingency Management Procedures to Manage Dialectical Dilemmas. American Journal of
Psychotherapy.

95
The Course and Evolution of Dialectical
Behavior Therapy

MARSHA M. LINEHAN, Ph.D., ABPP*


CHELSEY R. WILKS, M.S.
Dialectical behavior therapy was originally developed from early efforts to
apply standard behavior therapy to treat individuals who were highly
suicidal. Its development was a trial and error effort driven primarily from
clinical experience.
Dialectical behavior therapy is a modular and hierarchical treatment
consisting of a combination of individual psychotherapy, group skills, train-
ing, telephone coaching, and a therapist consultation team. The inherent
modularity and hierarchical structure of DBT has allowed for relative ease in
adapting and applying the treatment to other populations and settings. New
skills have been developed and/or modified due to clinical need and/or
advancement in research such as treatment outcomes or mechanisms. There
has been an effort to implement DBT skills as a standalone treatment. More
research is needed to assess how DBT skills work and for whom. As DBT
broadens its reach, the treatment will continue to grow and adapt to meet
demands of an evolving clinical landscape.

KEYWORDS: Dialectical behavior therapy, suicide, borderline personality


disorder, evidence-based treatments.

HISTORY OF DBT
Dialectical behavior therapy (DBT) emerged from attempts to apply
standard behavior therapy to the treatment of highly suicidal individuals.
In essence, DBT was a trial-and-error clinical effort based on the applica-
tion of behavioral principles (Bandura, 1969) and social learning theory
(Staats & Staats, 1963; Staats, 1975) to suicidal behaviors (Linehan, 1981).
In the first randomized controlled trial (RCT), Linehan and colleagues
actively recruited the most severe, highly suicidal clients from local area
hospitals (Linehan et al., 1991). From the beginning the focus of DBT has

Behavioral Research and Therapy Clinics, University of Washington, Seattle, Washington. 3935
University Way Department of Psychology, Behavioral Research and Therapy Clinics, Box 351525,
University of Washington, Seattle, WA 98195-1525. e-mail: linehan@u.washington.edu
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

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AMERICAN JOURNAL OF PSYCHOTHERAPY

been to build a life worth living. The first complete draft of the
treatment manual focused primarily on ameliorating suicidal behaviors;
however, federal grant funding required that treatment outcome research
identify a mental disorder diagnosis. As a result, the first clinical trials
conducted were focused on treating chronically suicidal who also met
criteria for borderline personality disorder (BPD), a population known for
being at risk for suicide (Leichsenring, Leibing, Kruse, New, & Leweke,
2011).
Initially, treatment focused on teaching clients effective problem-solv-
ing strategies. However, treating such a high-risk and complex population
moved the therapists to apply treatment strategies that required clients to
make very difficult life changes. This focus on problem solving was
experienced as extremely invalidating by clients. Often, clients responded
with hostility by lashing out, often at their therapist, or dropping out of
treatment altogether. In response, treatment shifted dramatically to focus
on warmth and acceptance. Clients were equally frustrated by this treat-
ment, saying it was not doing enough to solve their problems. It became
clear was that there was a need for new therapist strategies that could
encompass a synthesis of
a) a technology of change and a technology of acceptance,
b) spaciousness of the therapists mind to dance with movement,
speed and flow,
c) radical acceptance by the therapist of the client as is, with slow and
episodic rate of progress and the constant risk of suicide, and
d) therapist humility to see the transactional nature of the enterprise.
This led to a synthesis of both acceptance and changeaccepting
clients where they are while pushing for progress and combining a range
of change strategies aimed at problem solutions and acceptance strategies
with a core emphasis on validation.
However, this synthesis of acceptance and change was troubling for
clients as well. Given the complexity of the clients problems, asking them
to temporarily tolerate distressing experiences to focus on other treatment
goals proved difficult if not impossible. For many clients, the pain from the
past was intolerable and elicited dysfunctional behaviors. What was
needed was a new set of client targets that focused on teaching
a) radical acceptance of what each of us has to accept; our past, the
present and realistic limitations on the future and
b) skills to tolerate distress without impulsively or destructively reduc-
ing it.
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Evolution of DBT

Dialectical behavior therapy is rooted in behaviorism, and at the time


DBT was created, behavioral treatments focused primarily on changing
distressing experiences rather than on temporally tolerating them. This
prompted an alteration to traditional behavioral treatment.
The problem was where to find an acceptance-based practice that did
not focus on change. Acceptance-based treatments (e.g. client centered
therapy; Rogers, 1946) used positive acknowledgement as a vehicle to
enact change, and thus were ultimately change focused. A search for
practices that were purely acceptance based, and for individuals who could
teach acceptance without linking it to change, led to the study of both
Eastern (Zen) and Western contemplative practices (Aitken, 1982; Jager,
2005). Fundamental to these practices is the concept of radical acceptance
of the present moment without attempts to change it. Integrating Zen and
contemplative practices into behavioral therapy also created challenges.
Both Zen and contemplative prayer spring from spiritual practices, and
clients presented from the entire spectrum from no spirituality to intense
spirituality and religious convictions. An inclusive approach had to be
developed. Many individuals struggled with meditating in silence and
focusing their attention on their breath and inner sensations. At the time,
meditation did not exist in psychotherapy. The idea of meditation was
viewed as weird, threatening, and out of reach to individuals whose
avoidance of emotions and inner sensations was a strong pattern. Thus,
basic Zen practices, along with aspects of other contemplative practices,
were translated into a set of behavioral skills that could be taught to both
clients and therapists. The spiritual and religious overtones in Zen had to
be parceled out as well, at least at first pass. Thus, the term mindfulness
was used to describe the skills translated from Zen. The term was adopted
from the work of both Ellen Langer (1989) and Thich Nhat Hanh (1976).
The skills translating contemplative practices were labeled reality accep-
tance skills and drew heavily from the work of Gerald May (1987).
Another problem to solve was to develop a model for BPD. Such a
model would have to be capable of guiding effective therapy, non-
pejorative for the client, and compatible with current research data. Thus,
the model that was developed was the biosocial theory, which states that
BPD is a pervasive disorder of the emotion regulation system. Taken
further, BPD criterion behaviors function to regulate emotions or are a
natural consequence of emotion dysregulation (Linehan, 1993).
Dialectical behavior therapy required a theoretical framework that
could integrate the principles of Zen and other contemplative practices
with behaviorism. That framework emerged with a chance encounter with
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AMERICAN JOURNAL OF PSYCHOTHERAPY

the philosophical concept of dialectics, which highlights the process of


synthesizing oppositions. After dialectics was adopted, the treatment was
scrutinized to insure that it was consistent with the underlying philosophy
and the treatment manual was published (Linehan, 1993a; Linehan,
1993b). Dialectics continues to provide a framework from which the
treatment evolves; continual tensions between theory and research versus
clinical experience and between Western psychology versus Eastern prac-
tice drives the evolution that is consistent with the theoretical integration
model described by psychotherapy integration researchers (Arkowitz,
1989; Arkowitz, 1992; Prochaska & Diclemente, 2005; Ryle, 2005; Nor-
cross & Goldfried, 2005).
STAGES OF TREATMENT
Clients coming into treatment ordinarily met criteria for BPD, were at
high risk for suicide, had a wide range of co-occuring axis I disorders (e.g.,
depression, multiple anxiety disorders, eating disorders, substance abuse
disorders, etc.), had a difficult time managing negative emotions, and were
engaged in behaviors antithetical to treatment (e.g., avoidance of appoint-
ments, poor time management skills), all of which made conducting
effective therapy difficult. At the time there were no guidelines on how to
treat clients with severe multiple disorders and high-risk behaviors, and
therapists needed guidance on what and how to prioritize problems within
sessions. To organize treatment, a set of priorities were developed based on
the concept of level of disorder, which included imminent life threatening
risk, severity, pervasiveness, and complexity of disorder and, disability.
The guidelines provide a hierarchy of what to treat and when to treat
it for a particular client. It also enables the clinician to treat individuals
with varying complexities and problems. Targets can be grouped into
recommended stages of treatment. In stage 1, the focus of treatment is to
stabilize the client and achieve behavioral control. Stage 1 is broken into
the following behavioral targets: to decrease imminent life interfering
behaviors (e.g. suicide attempts, non-suicidal self-injury), reduce therapy
interfering behaviors (e.g. missing treatment, behaviors that are burning
out the therapist, refusal to collaborate with necessary steps for desired
change), decrease client-guided, quality-of-life interfering behaviors (e.g.
substance use, unemployment, homelessness), and increase skillful behav-
iors to replace dysfunctional behaviors (this is called DBT skills training).
Stage 2 is called the stage of quiet desperation. Action is controlled but
emotional suffering is not. In stage 2, the goal of treatment is for the client
to experience to full range of emotions; also PTSD is treated in stage 2.
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Evolution of DBT

Figure 1

Stage 3 is to reduce ordinary problems in living. Stage 4 is designed to


increase a sense of completeness, to find joy, and/or achieve transcen-
dence.
MODULARITY
As previously mentioned, DBT was developed for clients with com-
plex, multi-diagnostic, high-risk disorders, and resultantly, the clinical
problems that emerged were very complicated. It was clear that in order
for DBT to be effective, treatment had to be flexible and based on
principles rather than on highly structured protocols. Strategies for ap-
proaching and resolving complex problems are modularity and hierarchy.
Modularity can be used to separate the functions of a treatment/interven-
tion into independent modules such that each module contains everything
necessary to carry out one specific aspect of the desired treatment. This
inherent modularity to DBT enables various aspects of disorder-specific
protocols to be included or withdrawn from the treatment as needed.
Hierarchy is built into the treatment by having predetermined levels of
disorder, which are addressed in order from most to least severe.
Dialectical behavior therapy was developed for individuals entering
stage 1 of treatment. However, DBT has a modular and flexible structure,
which allows for the treatment to be scaled to treat clients with simpler
clinical presentations. Disorders are treated depending on a treatment
hierarchy with protocols within DBT or protocols brought in from other
treatments for specific problems (for example, formal exposure for specific
phobias).
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TEAM AS A PART OF TREATMENT


Dialectical behavior therapy was developed and applied initially within
a graduate training program that evolved into a research environment.
After completion of formal DBT training and supervision, all research
therapists attended a weekly consultation team meeting to insure the
maintenance of fidelity to the model during the study. Because this was
and is the model used in all of the early DBT studies it, the treatment,
when defined, included this focus on team consultation as part of the
treatment. The primary functions of consultation team are to focus on
therapist treatment fidelity, manage burnout, and provide support to those
treating clients at imminent suicide risk and/or engaging in significantly
more dysfunctional behavior. In DBT, the emphasis of consultation team
reinforced and/or shaped therapist behavior, with the aim to improve
fidelity and treatment. The essence of team is to prioritize topics based on
severity and acuity. Therapists are also encouraged to cheerlead and
validate each other and to maintain a non-judgmental tone. Consequently,
DBT is defined as the treatment of a community of clients by a community
of therapists, and the treatment of the therapists by the community of
therapists.
BETWEEN-SESSION COACHING
The primary rationales for providing between-session telephone coach-
ing is that 1) suicidal individuals often need more contact than weekly
individual sessions, especially during crises, and 2) allowing phone calls
only when suicidal is likely to reinforce suicidality for many clients.
Another reason for phone coaching between sessions is that most clients
desperately needed to learn how to interact with people in ways that make
others want to help them rather than making others angry or frustrated.
Thus a focus of phone calls is to teach clients phone skills and to provide
effective consequences for dysfunctional social interactions. Phone skill
coaching is used to aid in skill generalization in different contexts and
environments. Lastly, phone coaching can be used to repair damage done
to the therapeutic relationship when having to wait until the next session
is unnecessarily painful.
DBT SKILLS
In developing the treatment it became apparent that it was extraordi-
narily difficult, if not impossible, in 60 minutes to focus simultaneously on
problem solving a range of crises, dysfunctional behaviors, emotional
distress and high emotion dysregulations while teaching a set of behavioral
skills that required practice to be useful. Accordingly, treatment was
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Evolution of DBT

separated into two parts serving differing roles, one that focused primarily
on skill training and one that focused primarily on solving current prob-
lems and motivational issues, (e.g. staying alive, abstaining from drug use,
reducing depression and/or stay in therapy). In DBT skills the primary
emphasis is to help clients learn behaviors that can be used in place of
ineffective or maladaptive behavior. Some attention to motivational issues
occurs in DBT skills training, particularly with the weekly skills practice
homework assignments, but the fundamental emphasis in DBT skills
training is on acquiring and strengthening skills.
Skills training is didactically focused, with a heavy emphasis on skills
training procedures, including modeling, instructions, stories, behavioral
rehearsal, feedback and coaching, and homework assignments. Skills for
each module are transcribed on handouts, and various worksheets are
provided for each skill. There are four skills modules
1) mindfulness,
2) interpersonal effectiveness,
3) emotional regulation, and
4) distress tolerance.
Skills are separated into change skills (interpersonal effectiveness and
emotion regulation) and acceptance skills (mindfulness and distress
tolerance). The inherent modularity of DBT allows for skills to be added,
modified, or deleted depending on the curriculum or need. Many of the
DBT skills are developed from research in social psychology, spiritual
teachings, or are adaptations of instructions given to clients in various
evidence-based treatments targeting specific problems. The original skills
package was developed for individuals who were highly suicidal and
diagnosed with BPD; since then, DBT has been implemented with differ-
ing populations and with individuals presenting with differing problem
behaviors. New skills have been developed and/or modified due to clinical
need and/or advancement in research such as treatment outcomes or
mechanisms. Further, the development of DBT was and continues to be an
iterative processas new research comes in, skills will naturally adapt to
improve treatment or address new challenges.
Mindfulness is central to DBT, and thus mindfulness skills are labeled
the core skills. These skills (going within to wise mind, wordless
observing, describing what is observed, participating, being non-judgmen-
tal, one mindfulness, and effectiveness) are behavioral translations of
common instructions given across Eastern and Western contemplative
practices. Each skills module has at least one mindfulness skill, e.g.,
mindfulness of others in interpersonal skills, mindfulness of current emo-
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tions in emotion regulation, and mindfulness of current thoughts in


distress tolerance. The mindfulness skills of observe and describe are
part of every worksheet.
Emotion regulation training teaches a range of behavioral and cognitive
strategies for reducing unwanted emotional responses and increasing
desired emotions. Skills focus on teaching how to identify and describe
emotions, how to change emotional responses, how to reduce vulnerability
to negative emotions, and how to manage difficult emotions. Dialectical
behavior therapy emotion regulation skills training first teaches that emo-
tions are brief, involuntary, full-system, patterned responses to internal and
external stimuli (Eckman & Davidson, 1994). Also emphasized in skills
training is the importance of the evolutionary adaptive value of emotions
in understanding them (Tooby & Cosmides, 1990). The first task of
emotion regulation skills training is presenting the model of emotion which
identifies
1) emotional vulnerability to cues,
2) internal and/or external events that, when attended to, serve as
emotional cues (e.g., prompting events),
3) appraisal and interpretations of the cues,
4) response tendencies, including neurochemical and physiological
responses, experiential responses and action urges,
5) non-verbal and verbal expressive responses and actions, and
6) after-effects of the initial emotional firing which can include
secondary emotions.
Many DBT skills target specific components of the emotional system
because we believe that if someone wants to change her emotions, includ-
ing emotional actions, it can be done by targeting any part of the system of
emotions. Once a model is formed, skills to change emotions largely come
from existing treatment manuals. Exposure based procedures are found in
the skill of Opposite Action, where clients explicitly do the opposite of
what their emotions and/or action urges dictate (e.g. approach a feared
stimulus). Since the original publication of the skills manual (Linehan
1993b), new research emerged for the treatment of depression (e.g.
behavioral activation [BA]; Dimidjian et al., 2006) and post-traumatic
stress disorder (e.g. prolonged Exposure [PE]; Foa, Hembree, & Roth-
baum, 2007). Subsequent research trials on BA and PE provided further
research support for opposite action for emotions like sadness or fear
respectively. New emotion regulation skills emerged to target specific
aspects of the model of emotions. For example, Nezu, Nezu, and Perris
(1989) problem solving therapy was repurposed to Problem Solving,
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Evolution of DBT

where solutions are generated to solve problems causing justified emo-


tional distress. Cognitive modification (e.g. Meichenbaum, 1979) became
the new skill of check the facts where unjustified emotions are chal-
lenged and events are reinterpretated to fit the facts. Imaginal rehearsal
was repurposed into Cope Ahead, where individuals imagine coping
effectively to a feared and/or distressing situation. Imaginal rehearsal is
also applied in the nightmare protocol (Krakow et al., 2001). In addition
to changing emotional response, emotion regulation skills also teach clients
to reduce vulnerability to negative emotions. Dialectical behavior therapy
is referred as a treatment that helps clients build a life worth living. To
emphasize that point, skills were added that taught accumulating positives
in both the short-term (e.g. adding pleasant events) and in the long-term
(e.g. developing goals that fit ones values). Both skills fit within the
behavioral activation treatment model for depression and are also similar
to the emphasis on values in acceptance and commitment therapy ([ACT]
Hayes, Strosahl, & Wilson, 1999).
Individuals with difficulty regulating their emotions often experience
difficulties in interpersonal relationships; for example, jealousy and anger
can damage close relationships, fear and shame can lead to avoidance of
interpersonal contact, and even depression can inhibit efforts to interact
with others. Thus interpersonal effectiveness training is a collection of
skills that teach individuals to manage interpersonal conflict, develop new
friendships and/or end destructive ones, and reinforce the environment
effectively. Many of the interpersonal effectiveness skills came from re-
search in assertiveness training (Linehan & Egan, 1979); for example, the
skill of DEARMAN (see figure 2) teaches individuals how to make
requests effectively. This is balanced by skills on how/when to effectively
say no. Interpersonal effectiveness skills have broadened to include skills in
dialectics, validation, and contingency management procedures. These
skills were added to address different interpersonal dynamics. For exam-
ple, Walking the Middle Path, was originally designed for family skills
training with adolescents and their care givers. In walking the middle path,
individuals are taught dialectics, more in depth validation (see Linehan
1997), and behavior change procedures. This includes a skill on behavior-
ism, which teaches clients how positive and negative reinforcement can be
strategically implemented to shape goal directed behavior.
When DBT was developed, there were no existing treatment manuals
that targeted temporarily tolerating distressing events or circumstances.
Available behavioral treatment focused on changing behavior, while dis-
tress tolerance teaches clients to accept, find meaning, and tolerate distress.
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AMERICAN JOURNAL OF PSYCHOTHERAPY

Figure 2
DEARMAN ACRONYM FROM INTERPERSONAL EFFECTIVENESS MODULE

Distress tolerance training teaches a number of delay of gratification and


self-soothing techniques aimed at surviving crises without making things
worse (e.g. avoiding using drugs, attempting suicide, or engaging in other
dysfunctional behavior). For example, the TIP skill (see figure 3) was
developed by translating research on how to activate the bodys physio-
logical nervous system for decreasing arousal either through temperature
(Jay, Christensen, & White, 2006 & Foster & Sheel, 2005), exercise (Tate
& Petruzzello, 1995), effective breathing , and muscle relaxation (Linehan,
2005). Also, in distress tolerance are a set of skills focused on reality
acceptance, which aim to reduce suffering and increase freedom when
painful facts cannot be changed immediately (if ever). The skill of radical
acceptance, for example emerged from the extensive literature on survi-
vors of Nazi concentration camps, particularly the work by Viktor Frankl
(1985). Luck plus radical acceptance of the facts of the present moment
were essential to survival.

Figure 3
TIP ACRONYM FROM DISTRESS TOLERANCE MODULE

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Evolution of DBT

Figure 4

The skill of willingness, contrasted with willfulness, was taken from


Gerald Mays (1982) book and it teaches clients to be wholeheartedly
ready to respond to lifes challenges, doing what is necessary, and throwing
ones self into the community as a whole. Among the reality acceptance
skills are ones that are accepting reality with the bodythese are half
smiling and willing hands. Half smiling came from research that showed
that emotions are influenced by facial expressions (Ekman et al., 1987 &
Ekman, 1993). For the treatment of substance abuse, a new set of skills
that highlighted drug addiction were added to the distress tolerance
module. These skills integrate community reinforcement, alternative rebel-
lion, and the concept of dialectical abstinence, which is a synthesis of an
abstinence approach with a harm reduction approach. Very recently, the
TIP skill within the distress tolerance module was modified to include a
skill called paired muscle relaxation. Adapted from stress management
for collegiate and professional athletes (Smith, 1980), paced muscle relax-
ation pairs induced affect, cognitive modification, and relaxation.
FUTURE DIRECTIONS
Beyond treating clients with BPD, DBT has demonstrated efficacy with
different conditions, such as eating disorders (Safer & Jo, 2010; Safer &
Joyce, 2011), depression in older adults (Lynch et al., 2007; Lynch Morse,
Mendelson, & Robins, 2003), and a cluster B personality disorder (Feigen-
baum et al., 2011). In addition, there has been an effort to implement DBT
skills as a stand-alone treatment. A number of articles have identified that
the DBT skills component alone (without the individual therapy) to be
efficacious for a variety of populations including incarcerated women with
histories of trauma (Bradley & Follingstad, 2003), ADHD (Hirvikoski
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AMERICAN JOURNAL OF PSYCHOTHERAPY

et al., 2011), and for intimate partner violence (Iverson, Shenk, & Fruz-
zetti, 2009) among others. More research is needed to identify which skills
are effective for which problem area and for whom; though, DBT skill use
as a whole has been found to be effective at reducing emotion dysregula-
tion (Neacsiu, Rizvi, & Linehan, 2010). Dialectical behavior therapy skills
training has been applied to focus on building resilience and it can be
applied across work or school settings; for example, DBT skills lesson
plans are now being used in school systems to teach middle and high
school students (Mazza, Mazza, Murphy, Miller, & Rathus, in press). A
relative recent advance to psychotherapy is the integration of technology to
psychotherapy. For example, computerized psychotherapy treatments
have been found to reduce depression (Richards & Richardson, 2012;
Proudfoot et al., 2003) and anxiety (Marks, Kenwright, McDonough,
Whittaker, & Mataix-Cols, 2004). In some cases, the computerized inter-
ventions have been found to be as efficacious as face-to-face interventions
(Selmi, Klein, Greist, Sorrell, & Erdman, 1990). Dialectical behavior
therapy, with its established efficacy in face-to-face interventions for a
variety of clinical problems and populations and its structured skills
training format, is an ideal candidate for dissemination as a computerized
intervention.

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110
Transdiagnostic Applications of DBT for
Adolescents and Adults

LORIE A. RITSCHEL, Ph.D.*


NORIEL E. LIM, Ph.D.
LINDSAY M. STEWART, Ph.D.
Dialectical behavior therapy (DBT) is an empirically supported treatment
that was originally developed for chronically suicidal adults. Since the
publication of the original treatment manual, DBT has been reconceptualized
as a treatment that is broadly applicable for individuals who have difficulties
regulating emotion. As such, the treatment can be applied transdiagnosti-
cally. Based on the flexibility and adaptability of the treatment, several
adaptations have been made to the original protocol. Considerable empirical
evidence now supports the use of DBT adapted for eating disorders, substance
use disorders, and posttraumatic stress disorder. Moreover, developmentally
appropriate adaptations have made the treatment applicable to youth sam-
ples. The current paper is geared toward practitioners and describes the
various ways in which DBT has been modified for use with various popula-
tions and age ranges.

KEYWORDS: emotion dysregulation; DBT, suicidality; nonsuicidal self-


injury

INTRODUCTION
Dialectical Behavior Therapy ([DBT]; Linehan, 1993) is an evidence-
based treatment that was originally developed for chronically suicidal
adults. DBT is often associated with the treatment of borderline person-
ality disorder (BPD), which is characterized by emotional, behavioral,
cognitive, intrapersonal, and interpersonal dysregulation (Linehan, 1993a).
Individuals with pervasive emotion regulation difficulties often engage in
ineffective, harmful behaviors, including chronic suicidal ideation, non-
suicidal self-injury (NSSI; e.g., cutting, burning), disordered eating, and
substance use, as a way to modulate affect (Klonsky, 2009). As such, the

* UNC Chapel Hill School of Medicine, Chapel Hill, NC and #3C Institute & 3C, Family Services,
Cary, NC; Emory University School of Medicine, Atlanta, GA. Mailing address: * 1901 N. Harrison
Avenue, Suite 100, Cary, NC 27513. e-mail: lorie_ritschel@med.unc.edu
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

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treatment is designed to mitigate this pervasive dysregulation by teaching


skills to disrupt and replace these harmful compensatory behaviors with
more effective coping strategies.
Although DBT historically has been linked with BPD, two factors have
led to the broader application of DBT to other clinical populations. First,
individuals with BPD tend to meet criteria for at least one additional
diagnosis; on average, a person diagnosed with BPD meets criteria for
approximately four additional disorders (Hamed et al., 2008) Thus, the
treatment was designed to target myriad presenting problems across a
range of diagnoses. Moreover, the empirical evidence for DBT demon-
strates that the treatment is effective not only for reducing the major
treatment targets of suicide and NSSI, but also associated psychological
difficulties, such as depression and trauma symptoms (Lieb, Zanarini,
Schmahl, Linehan, & Bohus, 2004). Accordingly, in recent years DBT has
become more strongly associated with pervasive emotion dysregulation,
rather than with BPD specifically. Because other psychological difficulties
can similarly be characterized as reflecting an inability to modulate painful
negative affect without engaging in dysfunctional coping strategies, the
treatment was thus expanded and modified to accommodate other pre-
senting problems, such as eating disorders, substance use disorders, and
trauma.
Dialectical behavior therapy offers a multi-modal, comprehensive, and
flexible treatment approach that can be used transdiagnostically with both
adults and adolescents who have a range of emotion regulation difficulties.
Standard DBT is a principle-based treatment that includes weekly indi-
vidual therapy, as-needed between-session coaching, weekly group-based
skills training, and weekly consultation team meetings for therapists (for a
description of modes, targets, and stages of treatment, see Linehan, this
issue). The essence of DBT lies in the therapists skillful blending of
acceptance- and change-based strategies (Linehan, 1993). Acceptance-
based strategies in DBT are based on the principles of Zen, wherein clients
learn to observe and describe their behaviors, thoughts, emotions, and
environments without judgment and without trying to change themselves
or their situations. Change-based strategies in DBT are based on the
principles of behaviorism and include interventions such as exposure,
contingency management, problem solving, and cognitive restructuring.
DBT therapists are able to weave acceptance- and change-based strategies
together based on a well-formulated case conceptualization and target
hierarchy, which combine to dictate the moment-by-moment focal point in
therapy sessions. This blend of strategies is critical for individuals with
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TRANSDIAGNOSTIC APPLICATIONS OF DBT

severe emotion dysregulation because it is likely they will experience


change without acceptance as invalidating of their difficulties, whereas
acceptance without change is insufficient to moving them toward their
goals.
DBT AS A TRANSDIAGNOSTIC TREATMENT APPROACH
The recent psychological literature has focused strongly on the con-
struct of emotion dysregulation as the common element across most
psychological disorders. Several treatments that have emerged in recent
years have focused explicitly on transdiagnostic therapeutic applications,
with emotion regulation as a primary treatment focus (e.g., the Unified
Protocol; Barlow et al., 2010). Because DBT targets problematic emotions
and behaviors that occur across a range of psychological disorders, it is
broadly applicable as a transdiagnostic treatment strategy (see Ritschel,
Miller, & Taylor, 2013). For example, in adolescents, suicide and nonsui-
cidal self-injury (NSSI) are commonly observed not only in the context of
BPD, but also in bipolar disorder (Goldstein et al., 2007), depression and
anxiety disorders (Lewinsohn, Rohde, & Seeley 1996), PTSD (Giaconia,
Reinherz, Silverman, Pakiz, Frost, & Cohen, 1995), and conduct disorder
(Lewinsohn et al., 1995). Based on its emphasis on case conceptualization
and behavioral targeting, DBT can be applied across these various diag-
nostic categories to address suicide and NSSI as well as the symptoms that
present within each diagnostic class. The flexibility and adaptability of the
treatment are accounted for by two factors: (1) DBTs emphasis on
balancing change and acceptance strategies, and (2) the focus on emotion
dysregulation as the common element in psychological distress and inef-
fective regulatory strategies, as opposed to a singular focus on specific
diagnoses or symptoms.
Since its development, DBT has been adapted for use with clients
across a variety of age ranges, diagnostic categories, and treatment settings
(Ritschel, Miller, & Taylor, 2013). In adult samples, the empirical literature
supports the use of DBT as a treatment for BPD comorbid with substance
abuse (Linehan et al., 1999) and PTSD (Harned, Korslund, & Linehan, in
press). Independent of a BPD diagnosis, empirical literature supports the
use of DBT for individuals with treatment-resistant depression (Harley,
Sprich, Safren, Jacobo, & Fava, 2008), eating disorders (Safer, Telch, &
Agras, 2001; Telch, Agras, & Linehan, 2001), and depression in older
adults with mixed personality features (Lynch et al., 2007).
Recently, DBT has been expanded for use with adolescents with a
variety of psychological disorders, including those with borderline person-
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ality features and who engage in suicidal behavior and/or NSSI (Mehlum
et al., 2014; Miller, Rathus, & Linehan, 2007). Other research supports the
use of DBT with adolescents diagnosed with the following Axis I disor-
ders: eating disorders (Salbach-Andrae et al., 2009), bipolar disorder
(Goldstein, Axelson, Birmaher, & Brent, 2007), and oppositional defiant
disorder (Nelson-Gray et al., 2006). Additionally, DBT is a promising
intervention for juvenile offenders (Trupin, Stewart, Beach, & Boesky,
2002).
Although a thorough review of each of these adaptations is beyond the
scope of the current paper, in the pages that follow we review three of the
DBT modifications that have the strongest empirical support (i.e., for
substance use, eating disorders, and trauma). We also review one of the
newest adaptations of DBT for individuals on the opposite end of the
emotion dysregulation dialecticindividuals with emotional overcontrol
and affective inhibition. We will focus our efforts here on the clinical
adaptations that have been made for each of these modifications, although
the empirical studies supporting these approaches are documented
throughout.
DBT FOR SUBSTANCE USE DISORDERS (DBT-SUD)
Research has shown a high degree of comorbidity between substance
use disorders (SUDs) and BPD. In fact, studies indicate that among
individuals receiving treatment for BPD, between 21% and 67% also meet
criteria for SUDs (Dulit, Fyer, Haas, Sullivan & Frances, 1990). Due to this
overlap, as well as the tendency of individuals with comorbid BPD and
SUDs to present with greater psychiatric difficulties than individuals with
either disorder alone (Linehan et al., 1999), standard DBT has been
adapted to address comorbid substance use problems. Several studies have
shown support for the effectiveness of DBT-SUD for this population
(Linehan et al., 1999, 2002).
Similar to the conceptualization of NSSI as a way to regulate intense
negative emotions, substance use in DBT is viewed as a learned behavior
whose function is to modulate painful emotions and negative mood states,
such as sadness, boredom, shame, emptiness, rage, and misery. Because
substance use is conceptualized as a form of behavioral dyscontrol, and not
explicitly as a means of self-injury, it falls under quality of life interfering
behavior in the treatment target hierarchy (unless, of course, drugs were
taken as an intentional means to die by suicide, in which case it becomes
the number one treatment target). Thus, the overall goals of DBT-SUD
are to:
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(1) teach emotion regulation skills that reduce the need to engage in
dysfunctional emotion regulation strategies,
(2) reduce behaviors and obstacles that significantly interfere with
quality of life and maintain drug-seeking behavior, and
(3) promote more skillful behaviors that would allow individuals to
function adaptively and create a life worth living.
Dialectical behavioral therapy for substance use disorders uses the
same treatment modalities as standard DBT: clients are required to attend
weekly individual therapy as well as skills-training group. Coaching calls
and therapist participation in weekly consultation team meetings are also
part of the treatment. The major departure from standard DBT lies in the
significant emphasis DBT-SUD places on substance abuse and related
behaviors. More specifically, DBT-SUD employs many of the strategies
that have been shown to be successful in other substance abuse treatments;
in fact, extant literature underscores many commonalities between DBT-
SUD and more established substance abuse treatments (McMain, Sayrs,
Dimeff, and Linehan, 2007). For instance, like relapse prevention ([RP];
Marlatt & Gordon, 1985), DBT-SUD uses problem-solving strategies (e.g.,
chain analyses; Rizvi & Ritschel, in press) to target high-risk interpersonal
and contextual factors that are likely to precipitate relapse. Similar to
motivational interviewing ([MI] Miller & Rollnick, 1991), DBT-SUD
employs various strategies to enhance motivation to change (e.g., the use of
devils advocate as a commitment strategy) and utilizes validation strategies
that center on empathy and acceptance. Dialectical behavioral therapy for
substance use disorders also has some similarities to the 12-step approach
(Alcoholics Anonymous, 1981); that is, both interventions emphasize
abstinence as the ultimate treatment goal, use contingency management
and reinforcement strategies to maintain abstinence, and recognize the
importance of a community of individuals for recovery and support. Both
also incorporate spiritual principles (Christianity in AA; Zen in DBT).
Nevertheless, DBT-SUD differs from these approaches in that it is a
comprehensive and integrated treatment with equal emphases on absti-
nence and harm reduction (compared to RP), requires significant time
commitment (compared to MI), and views substance abuse as a learned
behavior rather than a disease (compared to 12-step approaches).
DIALECTICAL ABSTINENCE
Just as the dialectical balance between acceptance and change is the
foundation of standard DBT, DBT-SUD rests on the concept of dialectical
abstinence. Dialectical abstinence has been defined as a synthesis of
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unrelenting insistence on total abstinence before any illicit drug abuse with
an emphasis on radical acceptance, nonjudgmental problem-solving, and
effective relapse prevention after any drug use followed by a quick return
to the unrelenting insistence on abstinence (Dimeff, Rizvi, Brown &
Linehan, 2000, pg. 458). Because focusing on abstinence alone often leads
to notable challenges (e.g., giving up, hopelessness) when clients relapse,
dialectical abstinence balances the goal of absolute abstinence with a
nonjudgmental problem-solving approach to setbacks. The negative emo-
tions that clients typically experience after a relapse bring about conditions
that make it more likely for individuals to continue to abuse substances, a
phenomenon Marlatt and Gordon (1985) called the abstinence violation
effect (AVE). Whereas insistence on absolute abstinence helps prolong the
period between drug use episodes, relapse prevention helps to decrease
the frequency and intensity of relapse following a period of abstinence
(McMain, Sayrs, Dimeff & Linehan, 2007).
A common DBT strategy on the abstinence pole of the dialectic is to
help individuals initially commit to shorter periods of abstinence. Thus,
the goal is to keep clients drug-free by helping them link together shorter,
time-limited drug-free periods, with increasingly longer durations of total
abstinence and increasingly shorter durations of time spent in relapse.
Therapists teach skills to help clients learnand practice cognitive
self-control strategies that aim to convince ones brain that drug use is not
an option (Dimeff, Rizvi, Brown, & Linehan, 2000). The scope of absti-
nence (i.e., discontinuing all drug use vs. only the substances associated
with the most significant impairment) depends upon the therapists case
conceptualization (Dimeff & Linehan, 2008). For instance, if alcohol use
typically precedes cocaine use, abstinence from alcohol may be necessary,
even when the primary substance associated with impairment is cocaine.
On the relapse prevention pole of the dialectic, clients are reminded
that lapses occur in part because new behaviors need to be learned and
take time to become routine. The goal in this case is to help clients fail
well by preparing them to sustain the least amount of damage and to get
back on track quickly with the goal of total abstinence (McMain, Sayrs,
Dimeff & Linehan, 2007). Clients are encouraged to use just in case
thinking as a way to be planful about the possibility of relapsing in the
future. Dimeff and Linehan (2008) used a football quarterback analogy to
explain the process of dialectical abstinence: the goal is absolute absti-
nence, just as the ultimate goal in football is to get to the end zone to score
a touchdown. Dialectical behavioral therapy for DBT-SUD therapists, like
a quarterback, have to keep the team focused on the ultimate goal, only
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stopping briefly to help the client get back up during relapse (downs) and
quickly refocusing on the end goalnever dwelling on the slips along the
way. Failing well involves acceptance that one has relapsed, awareness of
the consequences of relapsing (including feelings of guilt and shame), and
reparation of the possible harm done to self or others.
Commitment and Attachment Strategies
Clients are considered to be in the pre-treatment stage of DBT-SUD
until they make a commitment to abstinence. Like butterflies that flutter in
and out of treatment, clients with SUDs often have difficulty attending
therapy regularly; thus, strategies were developed to increase clients
attachment to the treatment and the therapist. These strategies include:
orienting the client to possible attachment challenges at the beginning of
treatment, increasing contact with clients through planned check-in phone
calls between sessions, shortening or lengthening therapy sessions on an
as-needed basis, and having sessions that include family members and
friends to build connections with the clients social network.
PATH TO CLEAR MIND
In standard DBT, three states of mind are taught: emotion mind,
reasonable mind, and wise mind. In DBT-SUD, there are three analogues
to these states of mind: addict mind, clean mind, and clear mind. Addict
mind includes behaviors such as stealing or pawning goods to get money
for drugs, actively seeking drugs, planning to use, maintaining contact with
drug-using friends, and lying. Addict mind decisions are driven by im-
pulses, urges, and drug cravings. Individuals in clean mind have made the
decision to quit, and may even have successfully navigated a period of
abstinence; however, they are also oblivious to the potential for relapse and
are thus more vulnerable to future drug use. For example, they may
continue to spend time with drug-using friends, keep too much cash on
hand, or tell themselves that driving through their former dealers neigh-
borhood is not a problem.
Similar to the standard DBT goal of achieving greater amounts of time
in wise mind, the ultimate goal of DBT-SUD is attaining clear mind, in
which clients no longer use substances and simultaneously prepare for the
possibility of slipping back to abusing drugs (McMain, Sayrs, Dimeff, &
Linehan, 2007). Several strategies are used to help clients achieve dialec-
tical abstinence. First, therapists help clients track substance use with
observe and describe skills. Therapists home in on decreasing the intensity
and duration of cravings and urges to abuse illicit and prescription drugs
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through distress tolerance skills. Clients also learn to avoid cues associated
with drug abuse, including burning bridges to triggers associated with
drug use, including people (e.g., severing ties to drug contacts), places
(e.g., avoiding drug hang outs), or objects (e.g., discarding drug parapher-
nalia). Therapists help clients eliminate behaviors associated with drug use
(e.g., selling drugs or socializing with drug users) and reduce cues that
allow the client to retain drug use as an option (e.g., by getting a new
phone number and discarding drug dealers contact information). Finally,
therapists and clients work together on increasing clients healthy behav-
iors (e.g., pursuing social activities, making new friends) that support the
overall goal of abstinence.
TREATMENT ADAPTATIONS
A few strategies were adapted to meet the needs of clients who abuse
substances. Similar to standard DBT, DBT-SUD therapists prioritize
life-threatening and therapy-interfering behaviors over drug use, which is
generally considered a quality-of-life-interfering behavior. In some cases,
however, drug use may be treated as a behavior that leads to imminent risk
(e.g., drug overdose) or a therapy-interfering behavior (e.g., missing ses-
sions due to substance use, coming to sessions under the influence). In
these cases, substance use takes priority in individual therapy. Several
strategies relevant to substance use were added to the existing DBT skills
to address the challenges pertinent to individuals with SUDs (Dimeff &
Linehan, 2008). This includes adding alternate rebellion (i.e., satisfying
ones wish to rebel without engaging in drug use) and observing urges
skills to the mindfulness module; building a life worth living (by
developing structure in life) skill to the emotion regulation module;
adaptive denial (i.e., pushing away painful thoughts) and burning
bridges skills to the distress tolerance module; and eliminating cues to
use drugs as a self-management strategy. Finally, another modification in
DBT-SUD involves splitting the usual 150-minute skills group into a
90-minute skills group and a 30-minute individual skills consultation. This
change was adopted because empirical evidence (see Dimeff, Rizvi, Brown
& Linehan, 2000) suggests that a number of clients with SUDs also have
significant social anxiety, which prevents them from engaging fully in
group sessions. For this reason, group leaders found it necessary to meet
individually with group members to ensure that they are learning the skills.

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DBT FOR EATING DISORDERS (DBT-ED)


Eating disorders (EDs), including anorexia nervosa (AN), bulimia
nervosa (BN), binge eating disorder (BED), and eating disorder not
otherwise specified (EDNOS), are often chronic conditions associated
with high levels of impairment and psychological comorbidity. Studies
suggest that 15% to 40% of clients with BN attempt suicide (Dulit, Fyer,
Leon, Brodsky, & Frances, 1994); similarly, there is a strong association
between AN and completed suicide (Wisniewski, Safer, & Chen, 2007).
Empirically-supported treatments such as cognitive behavior therapy
(CBT) are estimated to be effective for only about half of individuals who
seek treatment for BN (Whittal, Agras, & Gould, 1999) and for an even
smaller percentage of clients with AN (Fairburn & Harrison, 2003). The
transdiagnostic flexibility of DBT makes it a viable treatment option for
individuals with a primary diagnosis of an ED who do not respond well to
traditional CBT as well as for individuals who meet criteria for both BPD
and an ED.
There is growing empirical support that DBT is effective for clients
with EDs, particularly in the areas of BN and BED (Safer, Telch, & Agras,
2001; Telch, Agras, & Linehan 2001). Several of the standard DBT skills
have been adapted for ED clients, including the inclusion of mindful
eating, urge surfing, and alternate rebellion. Mindful eating involves the
application of mindfulness what (observe, describe, and participate) and
how (one-mindfully, non-judgmentally) skills to the process of eating.
The urge surfing skill involves noticing the environmental cues that trigger
emotional eating and detaching from the ebb and flow of the urge through
active observation. Finally, alternate rebellion can be applied to help
individuals find other ways to rebel against society or peers whom they
perceive to be judgmental about their weight. Instead of binge eating out
of spite, clients are encouraged to find alternate modes of expression that
are consistent with their goals and values. While much of this research has
been conducted with adults, new evidence suggests that DBT-ED is
effective for adolescents as well (Salbach-Andrae et al., 2009).
To improve understanding about the etiology of eating disorders,
Wisniewski and Kelly (2003) adapted the biosocial theory of DBT. They
posited that in addition to having a biological susceptibility to emotion
dysregulation, clients with EDs are also susceptible to a nutrition-related
vulnerability that affects the bodys ability to regulate hunger cues. These
vulnerabilities are thought to transact with an invalidating environment to
create maladaptive behaviors, such as restricting, binge eating, and/or
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purging. The invalidating environment may take the form of teasing about
weight from family members and peers, cultural pressures that promote an
ideal weight and size, and media attention on dieting and losing weight
(Wisniewski, Safer, & Chen, 2007).
Similar to DBT-SUD, the standard hierarchy of DBT treatment targets
can be readily adapted to incorporate behaviors specific to eating disor-
ders. As Wisniewski, Safer, and Chen (2007) highlight, ED behaviors are
considered to be life threatening when they pose an imminent risk of threat
either to the patient or another person. Examples of life-threatening
behaviors include vomiting in the context of severe electrolyte imbalance
or restriction in a low-weight patient with bradycardia. Consultation with
members of the medical team is advised to help determine whether or not
a specific ED behavior qualifies as life threatening. Examples of therapy-
interfering behaviors in DBT-ED include not completing food diary cards,
difficulties focusing in session due to being overly hungry or glucose
deficient, falling below an agreed-upon weight range, purging that nega-
tively affects medication absorption, and lying about weight either directly
or through surreptitious means (e.g. water loading prior to weigh-in).
Finally, quality-of-life-interfering behaviors specific to ED include restrict-
ing, binge eating, vomiting, excessive exercise, diet pill abuse, and other
weight-related compensatory behaviors (Wisniewski, Safer, & Chen,
2007). The emphasis of DBT on commitment strategies and therapist
support inherent in the consultation team are noteworthy aspects that
make DBT relevant in helping this historically difficult-to-treat population.
For detailed descriptions of applications of DBT to address eating disor-
ders, including diary card, sample commitment agreements, and therapeu-
tic pointers, see Wisniewski, Safer, & Chen (2007).
Another adaptation of DBT for EDs is the modification of secondary
treatment targets. As Wisniewski and Kelly (2003) discussed, a key dia-
lectical dilemma for individuals with ED relates to out-of-control binge
eating at one extreme and overcontrolled eating on the other. Similarly,
a dialectical dilemma may also be used to highlight extremes in exercising
(no exercise vs. excessive exercise). The balance between these extremes
promotes mindful and flexible eating and exercising behaviors. As in
DBT-SUD, the concept of dialectical abstinence relates specifically to
objective binge eating; its aim is to encourage clients to commit to
completely abstain from objective binge eating while at the same time
acknowledging that if a binge episode occurs, they can return to the goal
of abstinence from overeating and feeling out of control.
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DBT FOR COMORBID PTSD (DBT-PE)


While protocol-driven treatments such as prolonged exposure (PE;
Foa, Hembree, & Rothbaum, 2007) and cognitive-processing therapy
(CPT; Resick & Schnicke, 1993) have empirical support for treating
posttraumatic stress disorder (PTSD), research suggests that these treat-
ments by themselves are not as effective in treating more complicated
diagnostic presentations of trauma (van der Kolk & Courtois, 2005).
Indeed, PTSD, BPD, and nonsuicidal self-injury (NSSI) commonly co-
occur in community and clinical samples; Wagner, Rizvi, and Harned
(2007) estimated that around two-thirds of individuals with BPD have
experienced physical or emotional abuse in childhood, and an even higher
percentage report trauma in adulthood. Notably, individuals with comor-
bid PTSD and BPD have been reported to be significantly more likely to
engage in suicidal and self-harming behaviors (Harned, Korslund, Foa, &
Linehan, 2012). As a principle-driven therapy, DBT lends itself to address-
ing these multiple problems as well as the relationships between the
problems.
RATIONALE FOR DEVELOPMENT AND TREATMENT STRUCTURE
While research suggests that standard DBT has promise in stabilizing
clients who have a constellation of disorders and symptoms, (e.g., BPD,
PTSD, and NSSI), this population in particular has historically been
challenging to treat. Long-term treatment gains, particularly with respect
to PTSD symptoms, may be limited; for example, Harned, Chapman, and
colleagues (2008) found that after one year of DBT, the remission rate of
PTSD is approximately 35%. In addition, Barnicot and Priebe (2013)
found that clients with comorbid BPD and PTSD were less likely to reduce
their rates of NSSI compared to clients with BPD alone over a one-year
period. Overall, findings suggest that standard DBT may have a limited
direct effect on improving symptoms of PTSD.
Within the last several years, DBT researchers have developed and
evaluated an integrated treatment to address the challenges in treating the
constellation of symptoms of suicidal and self-injuring clients with BPD
and PTSD (Harned, Korslund, Foa, & Linehan, 2012; Harned, Korslund,
& Linehan, in press; Harned & Linehan, 2008). The treatment includes
one year of standard DBT in conjunction with the DBT Prolonged
Exposure Protocol (DBT-PE). This combined protocol was designed
specifically to target symptoms of co-occurring BPD and PTSD by incor-
porating DBT strategies with the PE protocol for PTSD (Foa, Hembree,
& Rothbaum, 2007). The PE protocol is included once clients have
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demonstrated that they are not imminently suicidal, have not made a
suicide attempt or engaged in NSSI within the last two months, are able to
use skills to tolerate intense emotions without trying to escape from them,
and are not engaging in significant therapy-interfering behaviors, such as
homework non-compliance. In addition, both the patient and therapist
must agree collaboratively that PTSD is the top treatment target. Treat-
ment is typically administered in two separate hour-long individual ses-
sions (with the same therapist) or in one extended 90-minute session of
DBT-PE and 30 minutes of DBT (Harned, Korslund, & Linehan, 2014).
Notably, the DBT-PE protocol utilizes specific DBT strategies and tech-
niques such as dialectics, irreverence, and validation alongside the stan-
dard PE elements of in vivo and imaginal exposure. The integrated
treatment also requires that the DBT-PE protocol be discontinued should
the patient experience a relapse in self-injurious behavior.
Case studies (Harned & Linehan, 2008), an open trial (Harned,
Korslund, Foa, & Linehan, 2012) and more recently, a pilot randomized
controlled trial (Harned, Korslund, & Linehan, in press) have suggested
that the integrated DBT-PE treatment is feasible to implement and leads
to large and significant improvements in suicidal ideation, NSSI, symptoms
of PTSD, dissociation, shame, anxiety, depression, trauma-related guilt
cognitions, and global functioning. Notably, the pilot randomized con-
trolled trial (RCT) compared standard DBT to DBT-PE and found that a
majority of completers in the combined therapy (60% to 100%) showed
significant improvement in all of the above-mentioned areas at follow up,
while a much lower percentage of participants in standard DBT (20%)
maintained sustained, significant improvement. The authors concluded
that providing integrated DBT-PE to high-risk BPD clients had a strong
impact in decreasing suicidal and self-injurious behaviors across the en-
tirety of treatment.
TREATMENT HIERARCHY
Dialectical behavior therapy emphasizes the behavioral analysis of
problematic coping strategies, such as NSSI, as a way to discern the
function and context of maladaptive emotion regulation strategies that
occur in individual who have suffered trauma. As Wagner, Rizvi, and
Harned (2007) highlight, the factors involved in the initial development of
a problem behavior may differ from the factors that maintain a problem
behavior. For example, a patient may have initially developed dissociative
symptoms in the context of abuse or another form of trauma but may
currently dissociate to avoid contact with negative emotions. The authors
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note that effective treatment requires two foci: (1) current factors that
maintain the dissociative behavior and the associated development of
emotion regulation skills and exposure to current cues for negative emo-
tion; and (2) in vivo and imaginal exposure to the index trauma, which is
undertaken after the individual has learned skills to manage negative affect
as a way to preclude the recurrence of urges and actions to commit suicide
or engage in NSSI.
The biosocial theory helps guide the case conceptualization of clients
who present with complex trauma histories. For example, personal threats
in the form of physical, sexual, and emotional abuse constitute an invali-
dating environment and are likely to contribute to pervasive emotion
regulation difficulties and ineffective compensatory regulation strategies.
In keeping with the biosocial theory, the therapist must incorporate both
validation and behavioral skills into the case conceptualization to help
address the learning histories and skills deficits of clients with BPD and
trauma histories. The case conceptualization, in turn, guides the order in
which treatment targets are addressed for clients with comorbid BPD and
PTSD.
Given the assumption that problem behaviors such as suicide attempts
and NSSI are the result of difficulty tolerating intense and painful emo-
tions, the immediate and extensive processing of traumatic events in the
absence of teaching skills to manage these behaviors is contraindicated for
these clients (Foa, Hembree, & Rothbaum, 2007; Linehan, 1993a). Indeed,
PTSD treatment guidelines note that these types of treatments are not
suitable for suicidal clients, and PTSD studies routinely exclude clients
who are suicidal or who are engaging in NSSI (Bradley, Greene, Russ,
Dutra, & Westen, 2005). Thus, the first stage of DBT focuses on mini-
mizing life-threatening behaviors, increasing skills, and fostering a connec-
tion with the therapist. The focus is to help the patient learn to modulate
their emotions while maintaining contact with emotion cues. Wagner,
Rizvi, and Harned (2007) highlight that while trauma symptoms may
initially be targeted to the extent that they contribute to life-interfering
behaviors (e.g. NSSI), direct treatment of trauma is reserved for when a
patient has the skills to effectively tolerate intense emotional re-experienc-
ing.
RADICALLY OPEN DBT (RO-DBT)
One of the newest adaptations to standard DBT is radically open DBT
(RO-DBT; see Lynch et al., this volume; Lynch et al., 2007), which was
designed to be a transdiagnostic treatment that focuses on problems
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associated with emotional overcontrol. While emotional control is empha-


sized and valued in many societies and cultures, excessive inhibition has
been shown to increase the risk for interpersonal difficulties, social isola-
tion, and persistent mental health problems (Lynch et al., this volume).
Overcontrolled individuals are characterized as being very rigid and
perfectionistic, avoiding risks and new situations and lacking spontaneity
and emotional expressivity. The goal of RO-DBT is to help these individ-
uals flexibly adjust to changing environmental demands.
In comparison to standard DBT, the primary dysfunction treated in
RO-DBT is emotional loneliness stemming from social ostracism. Rooted
in Linehans (1993a) biosocial theory, RO-DBT posits that problems with
emotional overcontrol result from the transaction between: (a) a biological
predisposition to be particularly sensitive to threat and unaffected by social
rewards; and (b) environmental experiences that place excessive impor-
tance on avoiding mistakes and maintaining self-control. The biological
component of the theory suggests that overcontrolled individuals tend to
experience heightened threat arousal, which precludes them from feeling
safe and comfortable in social interactions. This arousal is associated with
increased sympathetic nervous system activity and decreased activity of the
facial muscles, resulting in blank or scowling facial expressions that tend to
increase the likelihood of social rejection and isolation. Thus, the primary
aim in RO-DBT is to teach clients skills that increase their sense of safety
in social situations and enable them to express emotions more genuinely
and fluidly during social interactions in order to prevent rejection.
Radically open DBT uses the same treatment modalities as standard
DBT (i.e., individual therapy, skills training, coaching calls, and consulta-
tion team). Similar to standard DBT, the first objective in individual
therapy is to reduce life-threatening behaviors. Next, RO-DBT therapists
emphasize the repair of alliance ruptures and conceptualize interpersonal
conflicts as opportunities for clients to learn that conflicts enhance rela-
tionship closeness. Attending to alliance ruptures allows clients to repair
relationships, rather than succumbing to the urge to avoid or abandon
relationships. Finally, individual therapy aims to decrease maladaptive
behaviors related to emotional overcontrol, such as emotional inhibition,
behavioral avoidance, rigidity in thoughts and behaviors, emotional dis-
tancing in relationships, and negative affect that results from social com-
parison and failure to achieve personal goals.
In addition to the original four skills modules in standard DBT,
RO-DBT incorporates a new module of radical openness skills to address
the emotional and behavioral deficits often seen in overcontrolled individ-
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uals. The skills taught in the module are designed to increase openness and
flexibility to new ideas, decrease avoidance, improve responses to inter-
personal feedback, increase trust, empathy and validation of others, and
decrease feelings of bitterness and envy through forgiveness and compas-
sion. Unlike the skill of radical acceptance that is taught in standard DBT
(wherein individuals are taught to accept reality as it is without trying to
change it), radical openness skills help clients to: (a) be more aware of
environmental cues that do not fit their beliefs or ideas about how the
world works, (b) engage in self-inquiry to challenge typical response
patterns, and (c) respond flexibly and effectively based on feedback from
the social environment. Such strategies are useful in enhancing cognitive
flexibility in overcontrolled individuals who tend to hold rigid beliefs and
worldviews.
Radically open DBT incorporates several other adaptations to the skills
training modules used in standard DBT. For example, the original states of
mind concept was replaced with three new states of mind: fatalistic mind,
in which the individual views change as unnecessary because there is no
answer, fixed mind, in which the individual views change as unnecessary
because I already know the answer, and flexible mind, in which the
individual is open to the possibility of change in order to learn.
Of note, wise mind differs from flexible mind in that the former empha-
sizes intuitive knowledge (I know to be), while the latter encourages
self-inquiry and the challenging of preconceived ideas. In addition, the
mindfulness module of RO-DBT teaches clients to observe the urge to fix
or correct as transitory and optional, much as standard
DBT teaches clients to observe urges to act on emotion in unskillful
ways and to let the urge pass without action. The emotion regulation
module of RO-DBT promotes experience and expression of emotions and
actively teaches clients to notice and avoid the urge to mask feelings.
Interpersonal effectiveness skills in RO-DBT focus on decreasing social
isolation, while self-soothe and radical acceptance are the most relevant
distress tolerance skills for overcontrolled individuals.
CONCLUSION
Due in large part to the flexible integration of acceptance and change-
based strategies, DBT is an ideal treatment to be modified for transdiag-
nostic applications. Dialectic behavior therapy relies on effective and
accurate case conceptualization strategies that allow the therapist and
client to collaboratively address multiple diagnostic and quality-of-life
related issues across the course of treatment. In addition, because DBT is
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a principle-driven treatment that incorporates as-needed protocols, it


seamlessly allows the therapist to dialectically blend the essential elements
of DBT (e.g., structural strategies, communication strategies) with empir-
ically supported protocols for co-occurring diagnoses such as eating
disorders, PTSD, and SUDs. Moreover, avenues exist to further expand
the transdiagnostic reach of DBT by incorporating evidence-based treat-
ments for additional comorbid diagnoses, such as panic disorder. As we
have noted elsewhere (Ritschel, Miller, & Taylor, 2013), comprehensive
DBT is an intensive treatment requiring considerable training for thera-
pists and a sizable commitment from clients; as such, we are careful to note
that we are not suggesting that full package DBT should be used when a
more parsimonious, streamlined approach is available and likely to be
equally or more effective (e.g., CBT for major depression). However, for
individuals with comorbid diagnostic presentations, or whose difficulties
are driven by a primary difficulty regulating emotions combined with the
repetitive use of ineffective coping strategies, such as disordered eating or
substance use, adapted versions of DBT may be just what the doctor
ordered.

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Dialectical Behavior Therapy and Eating
Disorders: The Use of Contingency
Management Procedures to Manage
Dialectical Dilemmas

LUCENE WISNIEWSKI, Ph.D.*


DENISE D. BEN-PORATH, Ph.D.#
Several researchers have adapted and/or applied dialectical behavior therapy
(DBT) for populations with eating disorders. There is a growing body of
research that indicates that DBT is an effective treatment option for this
population, including those who have co-occurring Axis II disorders. The goal
of the current paper is to summarize the research conducted in the area of
DBT with those individuals who present with eating disorders only as well
as those who present with both eating disorders and Axis II disorders. We
also describe a dialectical dilemma, apparent compliance vs. active defiance,
which is commonly observed in the group with comorbidities A DBT change
strategy, contingency management, is discussed as an intervention to target
apparent compliance and active defiance.

KEYWORDS: dialectical behavior therapy, eating disorders, contingency


management

INTRODUCTION
Several randomized controlled trials have indicated that DBT is an
efficacious treatment for suicidal patients diagnosed with borderline per-
sonality disorder (Koons et al., 2001; Linehan, Armstrong, Suarez, Allmon,
& Heard, 1991; Linehan, Comtois, Murray, Brown, Gallop, & Heard,
2006; Linehan, Heard, & Armstrong, 1993). Indeed, Division 12 (Clinical
Psychology) of the American Psychological Association listed DBT as one
of four empirically supported treatments (ESTs) for borderline personality

*The Emily Program Cleveland and Case Western Reserve University, Cleveland, OH; #John
Carroll University, University Heights, OH. Mailing address: The Emily Program Cleveland, Case
Western Reserve University, Cleveland, OH. e-mail: lucene.wisniewski@emilyprogram.com
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

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disorder (BPD) and the only EST that has strong research support for
treating BPD (Society of Clinical Psychology, 2013).
Since the inception of DBT, several researchers have adapted and
applied it to various populations that stand to benefit from this treatment.
Because medical complications associated with eating disorders are com-
mon, and can become life-threatening, the treatment hierarchy in DBT
provides a useful frame to address the myriad complex therapy issues.
Additionally, some theorists have argued that eating disorder symptoms
represent a maladaptive method to regulate negative affect (Heatherton &
Baumeister, 1991; Safer, Telch, & Agras, 2001; Telch, Agras, & Linehan,
2001). Therefore, because of its efficacy in treating emotion dysregulation
and the corresponding maladaptive behaviors, DBT has been suggested as
a promising intervention for those with eating disorders to regulate affect,
e.g., binge/purge behaviors (Federici, Wisniewski, & Ben-Porath, 2012;
Wisniewski, Safer, & Chen, 2007).
DBT APPLIED TO CLIENTS DIAGNOSED WITH EATING
DISORDERS: A REVIEW
To date several studies have examined the effectiveness of DBT for the
treatment of individuals with eating disorders, including those diagnosed
with binge eating disorder (BED), bulimia nervosa (BN) and anorexia
nervosa (AN). In the first randomized study of DBT and binge eating
disorder, Telch, Agras, and Linehan (2001) randomly assigned women to
DBT skills training and a wait-list control condition. Results indicated that
89% of participants who received DBT skills were abstinent from binge
eating as compared with only 12.5% in the wait-list control condition.
Similarly, Masson, von Ranson, Wallace, and Safer (2013) randomly
assigned participants to a DBT or a wait-list control condition. Dialectical
behavior therapy was self-directed and consisted of an orientation, a copy
of the DBT skills manual, and six 20-minute supportive phone calls over
the course of 13 weeks. At the end of treatment 40% of DBT participants
abstained from binge eating as compared to 3.3% in the wait-list control
condition.
In order to control for the possible nonspecific effects of therapy, Safer,
Robinson and Jo (2010) compared DBT with an active comparison group
therapy (ACGT) modeled after Markowitz and Sacks (2002) manual of
supportive therapy for chronic depression. Participants were randomly
assigned to either 20 group sessions of DBT or ACGT. Results indicated
that reductions in binge frequency were greater and achieved more
quickly. Abstinence rates for bingeing were higher for the DBT group than
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for ACGT group (e.g., 64% vs. 36%, respectively). Despite these earlier
gains, reported differences between groups were not maintained upon the
three-, six-, and 12-month follow up suggesting that DBT may be respon-
sible for the initial rapid treatment gains but not long-term therapy gains
in those with BED.
Given that symptoms of bulimia have been theorized to play a role in
regulating affect, several researchers have used DBT to treat individuals
with bulimia nervosa. For example, Safer, Telch, and Agras (2001), in a
randomized treatment study, assigned individuals diagnosed with binge/
purge behaviors to once-weekly individual DBT treatment or a wait-list
control group. At the end of 20 weeks, 28.6% of participants in the
DBT-treatment group were abstinent from binge eating/purging behaviors
as compared with no participants in the wait-list control condition. Hill,
Craighead, and Safer (2011) randomly assigned participants to weekly
sessions of DBT skills plus appetite-awareness training or to a six-week
delay-treatment control. The appetite awareness training done in conjunc-
tion with DBT skills assisted clients in identifying and responding to
internal hunger and satiety cues. At six weeks, the participants who were
receiving DBT plus appetite-awareness training reported significantly
fewer bulimic symptoms, had greater abstinence rates from binge/purge
behaviors, and were more likely to no longer meet full or subthreshold
criteria for BN as compared to the delay-treatment control group. At post
treatment, after both groups had received DBT treatment for a total of 12
weeks, 26.9% of the entire sample who had received DBT treatment was
abstinent from binge/purge episodes within the last month and 61.5% no
longer met criteria for bulimia.
Anorexia nervosa (AN), the eating disorder most refractory to treat-
ment, has received considerably less attention in the DBT literature. In an
effort to close this gap, two preliminary uncontrolled studies have been
conducted (Lynch, Gray, Hempel, Titley, Chen., & OMahen, 2013;
Salbach-Andrae, Bohnekamp, Pfeiffer, Lehmkuhl, and Miller, 2008)
Salbach-Andrae, Bohnekamp, Pfeiffer, Lehmkuhl, and Miller in their
25-week DBT program, found that women diagnosed with anorexia
demonstrated an appreciable weight gain post treatment and all individ-
uals diagnosed with AN-restricting type no longer met diagnostic criteria
post treatment. However, approximately half of the sample still met
criteria for AN-purging subtype, BN, or eating disorder-not otherwise
specified (ED-NOS). Lynch et al. (2013) have developed an adaptation of
DBT titled, radically open-DBT (RO-DBT) specifically for those individ-
uals who present with the restricting subtype of AN. In it they target
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emotional overcontrol. (This adaptation is described more in depth in this


volume.) In an uncontrolled trial with women diagnosed with anorexia
nervosa-restricting subtype, Lynch et al. (2013) found that after an average
of 21.7 weeks of RO-DBT treatment, 35% of these patients were in full
remission, and an additional 55% were in partial remission. A significant
increase in BMI post treatment was also found.
While the aforementioned studies show promise for the use of DBT in
those with eating disorders, none of these studies specifically sought out to
research individuals with eating disorders who also present with axis II
pathology, such as borderline personality disorder. Approximately 56% of
patients with ED present with Axis II pathology (Milos, Spindler, Budde-
berg, & Crameri, 2003). Indeed, some researchers have speculated that
patients with eating disorders who do not respond to treatment are likely
to also be diagnosed with borderline personality disorder (Johnson, Tobin,
& Dennis, 1990). Several studies suggest that patients with ED who have
comorbid personality disorders are likely to be those who do not respond
to traditional ED treatment and are perceived negatively by treatment
providers (Woollaston & Hixenbaugh, 2008). Research supports the idea
that patients with Axis II pathology are likely to respond to difficult
interpersonal situations with anger or lying (Mandal & Kocur, 2013). Our
clinical experience with this population supports these data and leads us to
believe that those with Axis II pathology are more likely to engage in
willful behaviors such as lack of transparency, angry outbursts, lying
behavior and refusing medical advice when prescriptive and proscriptive
approaches around their ED are employed. While these behaviors may be
evident in many individuals with borderline personality disorder, the
rule-bound nature of traditional eating disorder programs in which pro-
scriptive and prescriptive behaviors are enforced exacerbates these behav-
iors and tends to increase willfulness.
THE PROBLEM: BEING TOLD HOW TO MANAGE THE ED. THE RESULT: APPARENT
COMPLIANCE VS. ACTIVE DEFIANCE
Traditional ED treatment programs are rule bound by design. Patients
attending ED treatments generally receive a prescription regarding what,
when, and how much they can eat, drink, and move. At the same time
other behaviors, such as excessive cutting of food or use of condiments are
proscribed. The prescriptive and proscriptive model employed in tradi-
tional ED programs is effective for many, but not all ED patients.
Specifically, the prescriptions typically encountered in ED treatment (e.g.,
you must . . .) result in patients with eating disorders and borderline
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personality disorder refusing or rebelling against treatment providers (I


wont. . . you cant make me . . . .). The typical proscriptions (e.g., you
cannot . . .) result in similar responses (I will . . . . And you cant stop me!).
These reactive responses to being told what to do may cause negative
impact the therapeutic relationship., be seen by providers and loved ones
as signs of not wanting to get better and be those that lead patients to
be discharged from treatment prematurely. The prescriptions and pro-
scriptions typical of traditional ED treatments may unintentionally lead to
a dialectical dilemma, or extreme style of coping, for some patients.
DIALECTICAL DILEMMAS IN EDS: APPARENT COMPLIANCE VS.
ACTIVE DEFIANCE
In standard DBT, Linehan identified three dialectical dilemmas, or
behavioral extremes, common in BPD patients: Emotional vulnerability vs.
self- invalidation, unrelenting crisis vs. inhibited grieving, and apparent
competence vs. active passivity (Linehan, 1993). Within DBT theory,
emotionally vulnerable individuals [actions] have been reinforced and
therefore [they] learn to alternate between these extremes of over- and
under- regulation, thereby continuing to engage in ineffective behavior. In
previous writings, we described a common dialectical dilemma of eating
behavior: Rigid, over-controlled eating vs. absence of an eating plan
(Wisniewski & Kelly, 2003). We have recently identified a second di-
lemma: apparent compliance vs. active defiance.
The authors suggest that the term apparent compliance describes
behavior in which the patient reports engaging in a sufficient amount of a
behavior to demonstrate effort but does not engage in it enough to make
appreciable change. When engaging in apparently compliant behavior, the
ED patients behavior and words result in the illusion that she is following
through (i.e., complying) with treatment recommendations. As in standard
DBTs apparent competence, when the patient engages in apparently
compliant behavior, the environment will often attribute lack of change to
not trying or to manipulation. A typical example of apparent compliance
is represented in the following example. In a traditional ED program, a
client who is suffering from dehydration might receive a prescription to
drink 32 ounces of a calorie beverage daily and a proscription to refrain
from exercise until this medical problem is resolved. This client may report
to her therapist I am drinking Gatorade every day and havent gone to the
gym! Taken at face value, the statement I am drinking Gatorade every
day and havent gone to the gym appears as if the patient is compliant
with the treatment recommendations. However, upon further questioning
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by the therapist, the patient eventually describes that she drank only two
ounces of Gatorade each day and was jogging in her neighborhood. So
while the statement I am drinking Gatorade and havent gone to the gym
may be true, and it is also apparently compliant behavior.
Active defiance, at the other end of the dialectic, connotes behavior that
is willful and in opposition to treatment recommendations. An ED patient
is thought to be engaging in actively defiant behavior when she directly
refuses to follow treatment recommendations or program limits. The
patient who refuses to eat her therapeutic meal after having an argument
with another patient may be exhibiting actively defiant behavior.
The authors conceptualize apparent compliance and active defiance as
problematic since these behaviors necessitate that the therapist act like a
detective to obtain the full clinical picture. If apparently compliant or
actively defiant statements are taken at face value, they would mislead the
therapist about the patients progress and may block the therapist from
accurate assessment and recommendations regarding the patients prob-
lems.
The authors further conceptualize the patients apparently compliant
or actively defiant behavior in view of social learning theory. Specifically,
we theorize that in the development or maintenance of ED behavior, the
patient may have learned that apparently compliant behavior distracts
people (therapist, family, friends, teacher, or coach) from focusing ED
behaviors while actively defiant behaviors may prompt individuals to
decrease expected/desired change from the patient. Take for example, the
patient, who, after returning from a friends house, was asked by her
mother Did you and Jackie order pizza? When the patient answers yes,
moms anxiety and focus on patients eating decreases and the conversa-
tion ends. However, if the mom had asked more questions, she may have
found that her daughters answer was indicative of apparent compliance,
as although the pizza was ordered, the daughter hadnt eaten any of it! The
consequence of this apparently compliant behavior is that moms focus on
the patients eating decreases in that moment and the patient is not
blocked from or punished for ED behaviors.
An example of actively defiant behavior is noted in the case of Sue. Sue
comes to her individual therapy session and though she states that she is
following her meal plan 100% and is not exercising or purging, her weight
is down three pounds from the previous week When the therapist recom-
mends that Sue may need to increase food intake, she becomes dysregu-
lated and angry. She states that she is doing everything that is asked and
therefore she shouldnt be expected to eat any more than she is
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currently. Without the conceptualization of the angry/aggressive behavior


as active defiance, a therapist may blame the victim, and see this weight
loss as intentional, and fail to understand what help the patient actually
needs.
In order to address dialectical dilemmas, DBT therapists must focus on
secondary targets. Secondary targets in DBT are those issues addressed
after the primary targets (i.e., staying alive, behaviors that interfere with
therapy, behaviors that interfere with quality of life), yet still must be
tackled throughout treatment for an individual to learn to manage their
emotions. For each dialectical dilemma in DBT, there are at least two
secondary treatment targets (see Miller, Rathus, & Linehan, 2009, for a
more complete discussion) the aim of which includes decreasing maladap-
tive behaviors and increasing adaptive responses. With respect to the
dialectical dilemma of apparent compliance, the therapist needs to target
increasing actual compliance and decreasing passive, noncompliant behav-
ior. For active defiance the therapist focuses on an increase in willing, open
behaviors and communication and a decrease in refusal. The authors also
propose that the therapists use of contingency management strategies can
aid in the effective targeting of these dialectical dilemmas.
USING CONTINGENCY CONTRACTING TO ADDRESS APPARENT
COMPLIANCE & ACTIVE DEFIANCE
Contingency management is a general term in behavior therapy that is
based on the notion that the consequences of a behavior influence the
probability of the behaviors recurrence. Thus, it is possible to increase or
decrease the frequency of a behavior by influencing its associated conse-
quences. Reinforcement, punishment, extinction, shaping, and contin-
gency contracting are all examples of contingency management. Contin-
gency management has been widely used to treat various psychological
problems including substance abuse (Hartzler, Lash, & Roll, 2012), autism
(Kohler, et al., 1995), obesity (Stalonas, Johnson, & Christ, 1978), and
depression (Brannan & Nelson, 1987) by reinforcing adaptive, skillful
behaviors and extinguishing maladaptive behaviors. Contingency manage-
ment strategies may be a highly effective and valuable intervention for
patients with complex and multi-diagnostic presentations or patients with
recurrent therapy interfering behaviors (e.g., angry outbursts, lack of
weight gain, lying, etc.).
In response to our conceptualization of the dialectical dilemma of
apparent compliance vs. active defiance being triggered by being told how
to manage ED symptoms, our private group practice treatment center in
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the Midwest (Cleveland Center for Eating Disorders), has adjusted the way
we approach setting and evaluating goals with ED patients who attend our
DBT Day Treatment Program (see Federici & Wisniewski, 2011; 2013;
Federici, Wisniewski & Ben Porath, 2012 for a more through description
of the program and for whom this treatment is appropriate). We propose
that a collaborative use of contingency contracting can prevent or directly
address issues of Apparent Compliance and Active Defiance in eating
disorder patients.
SETTING STEP UP AND STEP DOWN CRITERIA USING
CONTINGENCY CONTRACTING
In our ED DBT program, we ask patients to make a commitment to
DBT for one year at any level of care (weekly DBT individual therapy (IT)
and skills group, intensive outpatient program, day treatment program).
While our goal is to help patients move themselves to the lowest level of
care possible, the treatment of ED behaviors generally requires treatment
and accountability at various levels of care over the course of the illness. In
standard ED programming, changes in level of care and goals of treatment
may be based exclusively on the American Psychiatric Association (APA)
practice guidelines for eating disorders (American Journal of Psychiatry,
2000), the program itself, or insurance company criteria. Instead, we
propose setting these criteria collaboratively between the patient and her
DBT therapist. This model allows the patient to decide how to manage
their own behavior. A patient sets goals and criteria for moving levels of
care, rather than this being set by the program. We attempt to link the
patients goals with what we have to offer (DBT treatment). We believe
that decreasing arbitrary consequences (something that seems to provoke
AC/AD behavior) allows the patient to take ownership of the goal as well
as if she is meeting the goal.
When a patient begins DBT for ED treatment at our center, she works
with her DBT therapist using contingency contracting to determine how
they will know that the patient will need or is ready to step up or down a
level of care. These criteria are set collaboratively and consider APA and
insurance criteria, case conceptualization, learning history, response to
previous treatment and most importantly, the patients wise mind (a DBT
skill that involves a synthesis of logic and emotion). These criteria include
observable information such as weight and vital signs, but also data
reported by the patient on DBT diary cards, such as self-harm, suicidality,
restriction, binge eating, purging, compulsive exercise and drug use (for a
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Dialectical Behavior Therapy and Eating Disorders

discussion around conceptualization of targets in ED behaviors see Wis-


niewski, Safer & Chen, 2007).
All attempts are made to set contingencies collaboratively while prac-
ticing wise mind (Linehan, 1993), and holding with the therapists and
patients needs/beliefs and understanding of the problem at hand as
equally relevant. If a disagreement in criteria arises, the therapist and
patient continue to discuss the difference until a synthesis is found or one
of the parties offers enough wise-minded evidence to convince the other
party to alter her opinion.
In order for this model/intervention to be effective, the patient needs
to understand behavior management and theory. We, therefore, teach
patients the ways that both classical and operant conditioning work.
Patients are taught to notice both the intended and potential unintended
consequences of their behavior as well as the fact that consequences can
affect behavior even without their awareness. Therefore, patients better
understand how to set goals that they want to meet and how to hold
themselves accountable for meeting or not meeting the goals, and thereby
decreasing the situations that are likely to trigger apparently compliant or
actively defiant behaviors.
The therapists job in contingency management is not to require the
patient to set a particular contingency for a target behavior; rather, the
therapists goal is to notice with the patient how her choice of contingen-
cies does or/does not lead to the patients desired outcome. By having the
patient set her own goals and contingencies, thereby decreasing the
therapists role in prescription or proscription, we believe that this will
decrease the need for the patient to employ apparently compliant or
actively defiant behaviors.
APPARENT COMPLIANCE: A CASE EXAMPLE
Lets consider the case of Mary, who is currently purging several times
per day and is trying to decrease this behavior. Mary wants to step down
to outpatient care as soon as possible because she wants to get back to her
job as a barista. Mary and her DBT therapist agree that during past
treatments Mary has lied about symptoms (demonstrating apparent com-
pliance) to be allowed to step down, and she wants to do things differently
this time. Mary has decided that decreasing purging to once a day or less
would be an indicator (among others) that she is ready to step down from
day treatment to outpatient care. Mary believes that the natural conse-
quences of feeling better about herself will motivate her to meet this goal.
They also discuss the potential for Mary to report apparently compliant
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behavior and how they will attempt to block this behavior (rating urges to
lie on diary card, asking her friends at work not to call her to cover shifts).
The DBT therapist suggests to Mary that relying on natural consequences
alone may not be sufficient to elicit change, given how hard it has been in
the past for Mary to change this behavior. Mary feels strongly that she is
in a different place and wants to try to set this goal using the natural
consequences for motivation for one week. The DBT therapist and Mary
agree that since she is currently medically stable, trying this goal for one
week is a reasonable plan.
After this one-week period, Mary and her DBT therapist observe that
Mary is purging more than twice a day. As part of DBT treatment, they
collaboratively conduct a behavior-chain analysis to understand what is
getting in the way of Mary meeting her goal. They discover jointly that the
thoughts of I will feel better about myself if I limit my purging are
fleeting and quickly overwhelmed by the anxiety of not purging. They note
urges to lie about purging behaviors are somewhat elevated and discuss
this. The DBT therapist then reviews learning theory withy Mary and
recounts how new behavioral patterns develop. Based on past personal
experience, Mary believes that working to avoid a negative consequence
will likely be more motivating for her to change behavior than setting up
a reward for limiting purging. Mary also believes that if she (rather than
others) controls the negative consequence, then she is less likely to use
apparently compliant behaviors. Mary, therefore, decides to look at a
picture of tooth decay (a natural negative consequence of purging) for 15
minutes on each day that she purges more than once. Based on previous
behavior-chain analyses that Mary and her therapist have conducted on
purging episodes, she is aware that one of the intended effects of purging
are to get rid of food that she has eaten to potentially avoid weight gain.
Mary decides that if she purges more than once each day, she will plan to
eat to replace the food she purged in order to block this goal. Once these
goals are collaboratively set, it is the therapists job to gently but firmly
guide the patient to hold herself to the criteria they have jointly identified.
CONCLUSION
There are strong data to support the use of modified, skills-only DBT
in treating patients with ED who are diagnosed with BED or BN. While
the data are still emerging, there does appear to be promising evidence for
the use of DBT in individuals who are also diagnosed with any ED as well
as with BPD. Future research in the form of randomized controlled trials
will be needed to solidify effectiveness of this model. That being said, there
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Dialectical Behavior Therapy and Eating Disorders

is a need in the literature for papers delineating conceptual and practical


strategies for use with this difficult population. The current paper detailed
a previously undescribed dialectical dilemma in the ED/DBT literature:
apparent compliance vs. active defiance. The authors suggest that the term
apparent compliance describes behavior in which the patient reports
engaging in or appears to display, a sufficient amount of a behavior to
demonstrate effort but not enough to make appreciable change; while
active defiance connotes behavior that is willful and in opposition to
treatment recommendations. The authors propose the development of this
dialectical dilemma in the context of learning theory and offer that the use
of collaborative contingency contracting to effectively address these be-
haviors. While there is some preliminary evidence to suggest that a more
flexible approach with ED patients also diagnosed with BPD is effective
(Federici & Wisniewski, 2013), future studies should attempt to isolate
whether this aspect of treatment may be contribute to better outcome.

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Radically Open-Dialectical Behavior
Therapy for Disorders of Over-Control:
Signaling Matters

THOMAS R. LYNCH, Ph.D., FBPsS*


ROELIE J. HEMPEL, Ph.D.*
CHRISTINE DUNKLEY, DClinP#
Radically Open-Dialectical Behavior Therapy (RO-DBT) is a transdiagnostic
treatment designed to address a spectrum of difficult-to-treat disorders shar-
ing similar phenotypic and genotypic features associated with maladaptive
over-controlsuch as anorexia nervosa, chronic depression, and obsessive
compulsive personality disorder. Over-control has been linked to social
isolation, aloof and distant relationships, cognitive rigidity, high detailed-
focused processing, risk aversion, strong needs for structure, inhibited emo-
tional expression, and hyper-perfectionism. While resting on the dialectical
underpinnings of standard DBT, the therapeutic strategies, core skills, and
theoretical perspectives in RO-DBT often substantially differ. For example,
RO-DBT contends that emotional loneliness secondary to low openness and
social-signaling deficits represents the core problem of over-control, not
emotion dysregulation. RO-DBT also significantly differs from other treat-
ment approaches, most notably by linking the communicative functions of
emotional expression to the formation of close social bonds and via skills
targeting social-signaling and changing neurophysiological arousal. The aim
of this paper is to provide a brief overview of the core theoretical principles
and unique treatment strategies underlying RO-DBT.

KEYWORDS: Radical openness; dialectical behavior therapy; social


signaling; psychological flexibility; emotion inhibition

INTRODUCTION
Until recently, the majority of treatment interventions targeting per-
sonality disorders (PDs), including standard dialectical behavior therapy

* School of Psychology, University of Southampton, Highfield Campus, Southampton, UK,


# Southern Health NHS Foundation Trust, Hampshire, UK. Mailing address: Thomas R. Lynch,
Professor of Clinical Psychology, School of Psychology, University of Southampton, Highfield
Campus, Southampton, SO17 1BJ, United Kingdom. e-mail: T.Lynch@soton.ac.uk
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

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(DBT), have tended to target borderline personality disorder (BPD)a


disorder characterized by low inhibitory control and dysregulated/impul-
sive behavior (see Dixon-Gordon, Turner, & Chapman, 2011 for review).
In contrast, radically open-dialectical behavior therapy (RO-DBT), a new
treatment approach with strong roots in standard DBT, targets a spectrum
of disorders sharing similar genotypic and phenotypic features linked to
excessive self-control or over-control (T. R. Lynch, in press; T. R. Lynch &
Cheavens, 2008; T.R. Lynch, Hempel, & Clark, 2015; T. R. Lynch et al.,
2013).
Over-control (OC) has been linked to social isolation, aloof and
distant relationships, cognitive rigidity, high detail versus global pro-
cessing, risk aversion, strong needs for structure, inhibited emotional
expression, hyper-perfectionism, social-isolation, and the development
of severe and difficult-to-treat mental health problems, such as chronic
depression, anorexia nervosa, and obsessive compulsive personality disorder
(Asendorpf, Denissen, & van Aken, 2008; Anderluh, Tchanturia, Rabe-
Hesketh et al., 2009; B.P.Chapman & Goldberg, 2011; A.L.Chapman, Lynch,
Rosenthal, et al., 2007; Eisenberg, Fabes, Guthrie, & Reiser, 2000; Riso et al.,
2003; Zucker et al., 2007). While resting on the dialectical underpinnings of
standard DBT, the therapeutic strategies, core skills, and theoretical perspec-
tives in RO-DBT often substantially differ. For example, RO-DBT contends
that emotional loneliness secondary to low openness and social-signaling deficits
represents the core problem of over-control, not emotion dysregulation as
posited in standard DBT (Linehan, 1993). Individuals characterized by over-
controlled coping tend to be serious about life, set high personal standards,
work hard, behave appropriately, and frequently will sacrifice personal needs
in order to achieve desired goals or help others; yet inwardly they often feel
clueless about how to join-in with others or establish intimate bonds. Thus,
over-control works well when it comes to sitting quietly in a monastery or
building a rocket; but it creates problems when it comes to social connected-
ness.
RO-DBT is supported by 20 years of translational research; including
two NIMH funded randomized controlled trials (RCTs) targeting refrac-
tory depression and comorbid OC personality dysfunction (T. R. Lynch et
al., 2007; T. R. Lynch, Morse, Mendelson, & Robins, 2003), two open-
trials targeting adult Anorexia Nervosa (Chen et al., 2014; T.R. Lynch et
al., 2013), one non-randomized trial using RO-skills alone for treatment
resistant adults with over-control (Keogh et al., in prep.), and a large
ongoing multi-center RCT targeting refractory depression and over-con-
trolled personality disorders (http://www.reframed.org.uk; Lynch chief
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Radically Open-DBT for Over-control: Signaling Matters

investigator). The aim of this paper is to briefly outline the theoretical


foundations of RO-DBT and to overview some of the unique structural or
treatment strategies that differentiate the treatment from standard DBT
and other treatment approaches targeting chronic and/or treatment resis-
tant disorders.
A TRANSDIAGNOSTIC PERSPECTIVE: SELF-CONTROL AS AN
OVERARCHING PRINCIPLE
RO-DBT posits that bio-temperamental deficits/excesses combined
with cultural or family values for self-control functions to handicap
openness, flexible responding, and cooperative social-signaling; resulting
in habitual over-control or under-control of socio-emotional behavior
(T. R. Lynch, in press; T.R. Lynch, Hempel, & Clark, 2015; T. R. Lynch
et al., 2013)sharing features with the well-established division be-
tween internalizing and externalizing disorders (Achenbach, 1966;
Crijnen, Achenbach, & Verhulst, 1997). Broadly speaking self-control
refers to the ability to inhibit emotional urges, impulses, and behaviors
in order to pursue long-term goals. Examples of under-controlled
disorders are conduct disorder, antisocial PD, borderline PD, and
binge-purge eating disorder; examples of OC disorders are obsessive
compulsive PD, avoidant PD, paranoid PD, and difficult-to-treat con-
ditions such as anorexia nervosa, autism spectrum disorders, and
chronic depression. Importantly, under-control and over-control are
not one-dimensional constructsthat is, they are not simply opposite
ends of a self-control continuum. They are labels used to describe a
complex set of bio-psycho-social behaviors shared by a spectrum of
disorders with similar genotypic/phenotypic features.
The above perspective has clear treatment implications; (i) treatments
should not assume client capabilities for openness and flexible responding
already exist, which emphasizes the need for skills-based approaches, and
(ii) undercontrolled problems require interventions designed to enhance
inhibitory control, delay gratification in order to achieve long-term goals,
plan ahead, and decrease impulsive mood-dependent behavior. Whereas,
over-controlled problems need interventions designed to relax rigid inhib-
itory control and increase openness, flexible-responding, pro-social signal-
ing, and emotional expressiveness. Thus, when it comes to treatment,
RO-DBT posits that one size does not fit allinstead core genotypic/
phenotypic differences between groups of disorders necessitate oftentimes
vastly different treatment approaches.
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Figure 1.
A NEUROBIOSOCIAL THEORY FOR OVER-CONTROLLED DISORDERS

A NEUROBIOSOCIAL THEORY FOR OVER-CONTROL


Radically open-DBT treatment strategies targeting loneliness and social
isolation are informed by a neurobiosocial theory (T. R. Lynch, in press;
T.R. Lynch, Hempel, & Clark, 2015; T. R. Lynch et al., 2013) that
deconstructs emotion regulation into three broad temporally sequenced
components:
(1) perceptual encoding factors (sensory receptor regulation) that pre-
cede
(2) internal modulatory factors (central-cognitive regulation) which
then result in
(3) social-signals or external behavioral expressions (response selection
regulation).
Separating overt behavioral regulation from internal central-cognitive
regulation helps explain why a person can feel anxious inside yet not
display any overt signs of anxiety on the outside.
Maladaptive over-control is theorized to develop and to be maintained
through a combination of three overarching factors associated with socio-
emotional well-being: bio-temperamental and genetic predispositions (na-
ture), family-environmental influences (nurture), and self-control tenden-
cies (coping). Specifically, bio-temperamental predispositions for heightened
threat sensitivity, diminished reward sensitivity, high inhibitory control
capacities, and superior attention for details are posited to transact with
early family/cultural experiences emphasizing mistakes as intolerable and
self-control as imperative, resulting in an over-controlled coping style that
limits opportunities to learn new skills and establish close social bonds (see
Figure 1).
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Radically Open-DBT for Over-control: Signaling Matters

Heightened OC temperamental threat sensitivity, diminished reward


sensitivity, and high detail-focused processing function to influence per-
ception; making it more likely that novel or discrepant stimuli will not only
be detected but evaluated at the sensory-receptor level as dangerous e.g.
when walking into a rose garden, the OC brain is more likely to notice the
thorns not the flowers, as well as the misaligned brick in the garden wall.
Over-controlled heightened bio-temperamental predispositions for high
self-control are often exacerbated by cultural or family-environmental
experience. The early environment of a client with OC has often punished
making mistakes, imprecision, requests for nurturance, displays of emo-
tion, and/or playful spontaneity. In contrast, the early environment often
rewards high tolerance of pain or distress, resistance of temptation, high
achievement and winning, rigid adherence to rules, and detection of minor
errors or discrepancies. Over-controlled coping emerges as a result of
these nature-nurture transactions.
A major component of the biosocial theory is that individuals who are
over-controlled often unintentionally bring mood states and associated
behaviors into social situations that function to isolate them from others.
Heightened OC threat sensitivity makes it more difficult for them to enter
into their neurologically based social-safety system (T. R. Lynch, in press;
T.R. Lynch, Hempel, & Clark, 2015; T. R. Lynch et al., 2013; T. R. Lynch,
Lazarus, & Cheavens, 2015). When an individual does not feel safe, the
autonomic nervous system is activated defensive arousal and fight or
flight responses become dominant. Facial expressions freeze, and we lose
the ability to flexibly interact with others. For the OC individual, defensive
arousal and frozen expression (or exaggerated insincere pro-social expres-
sion) is common. These behaviors are partly influenced by heightened
bio-temperamental threat sensitivity and partly influenced by social feed-
back from an early age implying that it is imperative to control oneself and
avoid an appearance of incompetence. As a consequence, clients who are
over-controlled work very hard to avoid mistakes, become increasingly
sensitive to perceived criticism, and base their self-worth on how their
performance compares to the performance of others. This can lead to
rigidly controlled and risk-averse styles of interacting that interfere with
new learning and the formation of social bonds (e.g., via automatic
rejection of feedback, avoidance of novelty or social situations, frozen or
disingenuous expressions, and compulsive desires for structure and order).
Unfortunately, extreme OC behavior elicits from others the very thing the
OC style is designed to prevent, that is people tend to avoid individuals
with OC and find their emotionally constricted, disingenuous, and inhib-
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ited style of expression uncomfortable to be around. Consequently, the


OC individual finds himself or herself increasingly isolated and lonely,
which exacerbates psychological distress.
Although both RO-DBT and standard DBT posit that emotions func-
tion to motivate actions and communicate intentions, RO-DBT differs from
standard DBT (and other treatments) by hypothesizing that in humans
emotions also function to facilitate the formation of strong social bonds
essential for species survival (via proprioceptive feedback; see T. R. Lynch,
in press). When compared to other animal species humans are not
particularly physically robust (e.g., we lack thick hides, protective fur, or
sharp claws). From an evolutionary perspective, our frailty necessitated the
development of a means to bond genetically diverse individuals in such a
way that survival of the tribe could override phylogenetically older selfish
response tendencies linked to survival of the individual. We hypothesize
that proprioceptive feedback and facial affect micro-mimicry reflect core
means by which this capacity is developed (see below). This capacity
provided us with a unique evolutionary advantageallowing us to form
strong social bonds and share valuable resources with other members of
our species who were not in our immediate nuclear family. Consequently,
RO-DBT strongly emphasizes the tribal nature of our speciespositing
that psychological well-being among humans depends greatly on our
visceral experience of social connectedness.
SIGNALING MATTERS
Research has demonstrated that masking inner feelings (or incon-
gruence between felt experience and displayed behavior) makes it more
likely that others perceive the incongruent person as untrustworthy or
inauthentic (e.g., Boone & Buck, 2003; Eisenberg et al., 2000; Kernis &
Goldman, 2006). This heightens defensive emotional arousal in those
interacting with the suppressor, and impairs the development of social
closeness (e.g., Butler et al., 2003; Srivastava, Tamir, McGonigal, John,
& Gross, 2009). In addition, individuals who habitually suppress
expressiveness report feeling more inauthentic and greater discomfort
with intimacy compared to those who do not suppress (Gross & John,
2003). Thus, signaling matters when treating clients who are over-
controlled: They are masters of self-control yet struggle communicating
openness, cooperation, and warmth essential skills needed to estab-
lish strong social bonds. In effect, the client has closed off a two-way
channel of communication with others. Firstly, the transmit channel
has been closed, preventing outward expression of private emotional
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Radically Open-DBT for Over-control: Signaling Matters

experiences. Secondly, the receive channel has been blocked, via


automatic rejection of corrective feedback.
Hence, RO-DBT links the communicative functions of emotion to
the formation of close social bonds. Social signaling skills taught in
RO-DBT emphasize methods to activate differing neural substratesin
particular the neural substrate associated with social-safety and activa-
tion of the parasympathetic nervous systems ventral vagal complex
([PNS-VVC] T. R. Lynch, in press; see also Porges, 2007). This enables
a client who over-controls to naturally relax facial muscles and non-
verbally signal cooperation and friendliness; thereby facilitating recip-
rocal cooperative responses from others and more fluid social interac-
tions. Moreover, RO-DBT uniquely posits that emotional expressions
in humans evolved to facilitate the formation of close social bonds and
altruistic behaviors among genetically dissimilar individuals. This is
supported by research showing that we automatically micro-mimic (in
milliseconds) the facial expressions of others, which triggers the same
brain structures (or mirror neurons) and physiological experience of
the mirrored person (Montgomery & Haxby, 2008; van der Gaag,
Minderaa, & Keysers, 2007). Thus, if we observe a person micro-
grimace in pain, we tend to without conscious awareness micro-
grimace and as a result, via the influence of the mirror neuron system
can viscerally know how the other person feels inside. The facilitative
function of emotion is hypothesized to represent a core component
linked to the development of sympathy, altruism, and empathy in our
species (T.R. Lynch, in press). It helps explain why humans are willing
to risk our lives to save (or fight for) genetically dissimilar others in our
tribe (e.g., fireman going into a burning building; clashes between rival
athletic teams; T.R. Lynch, in press). Consequently, RO-DBT empha-
sizes skills that take advantage of the mirror neuron system and our
natural tendencies to micro-mimic others in order to enhance social
connectedness. In addition, RO-DBT emphasizes skills designed to
activate the PNS-VVC social-safety system, increase vulnerable self-
disclosure, break-down over-learned expressive inhibitory barriers
(e.g., participation without planning and the art of being just a little bit
silly), and signal friendliness (e.g., leaning back in ones chair rather
than forward or raising eyebrows upward when stressed). The emphasis
on openness, social-signaling, micro-mimicry, and changing neurophys-
iological arousal differentiates RO-DBT from other therapeutic ap-
proaches; most notably those positing etiological factors linked to
metacognitive awareness, mentalization, emotion regulation, experien-
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Table 1. DIFFERENCES IN THERAPEUTIC STANCE BETWEEN STANDARD DBT


AND RO-DBT

Standard DBT RO-DBT

Therapist directedness often required in order to The therapist is less directive and encourages
stop dangerous impulsive behavior independence of action or opinion
Therapist may encourage brief disengagement from Therapist encourages engagement in conflict
conflict to reduce/avoid escalation rather than automatic abandonment or
avoidance
Major focus on emotion regulation skills and Major focus on social-signaling, openness, and
gaining behavioral control social connectedness
External contingencies, including mild aversives, Emphasis is on self-enquiry and self-discovery
help the client gain control and discover the rather than impulse control
reinforcing consequences of impulse control
Therapist recognizes that BPD clients need to do Therapist recognizes that clients characterized
better, try harder, and/or be more motivated to by over-control need to let-go of always
change striving to perform better or try harder
Therapist appreciates that the lives of suicidal, BPD Therapist appreciates that the lives of clients
individuals are unbearable as they are currently who over-control are miserable even though
being lived this may not always be apparent
Therapist recognizes therapy interfering behaviors Therapist recognizes therapeutic alliance
as problems necessitating change ruptures as opportunities for growth
Therapist rewards regulated and measured Therapist rewards candid disclosure and
expression of emotions and thoughts uninhibited expression of emotion

tial avoidance, acceptance, behavioral exposure and response preven-


tion, early childhood trauma, interpersonal problem solving, behavioral
activation, or cognitive restructuring.
THE THERAPEUTIC STANCE: DIFFERENCES BETWEEN
STANDARD DBT AND RO-DBT
The overall therapeutic stance used to teach skills to OC clients is
often dialectically opposite to approaches used in standard DBT. For
example, RO-DBT is less likely than DBT to emphasize skills that teach
how to avoid conflict, be more organized, restrain impulses, delay
gratification, or tolerate distress, because these skills are already over-
learned or engaged in compulsively by most OC individuals. Instead,
RO-DBT encourages clients to practice disinhibition, participate with-
out planning, be more open to critical feedback, and be more emo-
tionally expressive. Radical openness is not something that can be
grasped solely via intellectual means. Thus, RO-DBT requires therapists
to practice radical openness and self-enquiry themselves in order to
teach them to others e.g. clients who are over-controlled are unlikely
to believe it is socially acceptable for an adult to play, relax, admit
fallibility, or openly express emotions unless they see their therapists
model it first. A list of some of the core differences in therapeutic stance
between standard DBT (Linehan, 1993a) and RO-DBT is outlined in
Table 1.
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STRUCTURE OF TREATMENT
RO-DBT TREATMENT MODES AND TARGETS
The functions and modes of outpatient RO-DBT are similar to those in
standard DBT (Linehan, 1993a), including weekly one hour individual
therapy sessions, weekly skills training classes, telephone coaching (as
needed), and weekly therapist consultation team meetings (over a period of
30 weeks). The primary target/goal in RO-DBT is to decrease severe
behavioral over-control, emotional loneliness, and aloofness/distance
rather than decrease severe behavioral dyscontrol and mood dependent
responding as in standard DBT.
RO-DBT Orientation and Commitment
The orientation and commitment stage of RO-DBT takes up to four
sessions and includes five key components: 1) confirming self-identification
of over-control as the core problem, 2) obtaining a commitment from the
client to discuss in-person desires to drop-out of treatment before drop-
ping-out, 3) orienting the client to the RO-DBT neurobiosocial theory of
over-control, and 4) orienting the client to the RO-DBT key mechanism of
changei.e., open expression increased trust social connectedness. A
major aim of the orientation and commitment stage of RO-DBT is to
identify collaboratively the factors that may be preventing the client from
living according to their valued-goals. Values are the principles or stan-
dards a person considers important in life that guide behavior e.g. to
raise a family, to be a warm and helpful parent to ones children, to be
gainfully and happily employed, to develop or improve close relationships,
to form a romantic partnership. Whereas, goals are the means by which a
personal value is achieved e.g. working collaboratively on projects or
household chores in a manner that respects individual differences and
appreciates each persons contributions. From here, the therapist can
begin the process of identifying and individualizing treatment targets.
Treatment targets in RO-DBT prioritize maladaptive social-signaling be-
haviors that function to ostracize the client and exacerbate emotional
loneliness. For example, repeatedly re-doing other peoples work (e.g.,
re-wording an email, repacking the dishwasher) sends a powerful social-
signal (e.g., that others are incompetent or cannot be trusted) that nega-
tively impacts achievement of valued-goals related to social connectedness.
Thus, re-doing is an obstacle because it demoralizes coworkers and
family members, while exhausting the client because it means that they are
often working harder than nearby othersleading to resentment and
burnout. Finally, the orientation and commitment phase involves the start
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Figure 2.
RO-DBT INDIVIDUAL TREATMENT TARGET HIERARCHY FOR OVER-CONTROL

of individualized treatment targets linked to five OC themesin this case,


re-doing is linked to the theme rigid and rule-governed behavior (see
OC themes below).
RO-DBT Individual Therapy Treatment Targets
RO-DBT treatment targets are arranged according to a hierarchy of
importance; 1) reduce life-threatening behaviors, 2) repair alliance-rup-
tures, and 3) reduce OC social-signaling deficits and maladaptive overt
behaviors linked to OC themes (see Figure 2). Unlike standard DBT,
RO-DBT hierarchically targets therapeutic alliance ruptures over therapy-
interfering behaviors. Alliance-ruptures in RO-DBT are defined as: 1) the
client feels misunderstood, and/or 2) the client experiences the treatment
as not relevant to their unique problems. This is a major deviation from
standard DBT, where therapy-interfering behaviors are considered the
second most important target in the treatment hierarchy (after life threat-
ening). Broadly speaking, therapy-interfering behaviors in standard DBT
(Linehan, 1993a) refer to problem behaviors that interfere with the client
receiving the treatment (e.g., non-compliance with diary cards, not show-
ing for sessions, or refusal to speak during a session). In RO-DBT
alliance-ruptures are not considered problems; they are considered essential
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practice grounds for learning that conflict can be intimacy enhancing.


Crucially, clients who are over-controlled need to learn that expressing
inner feelingsincluding those involving conflict or disagreementis part
of normal healthy relationships. Since clients characterized by OC are
expert at masking inner feelings, a strong therapeutic alliance is not
expected to develop until mid-way through treatment (i.e., 14th ses-
sion)regardless of client statements of commitment or therapist exper-
tise. Consequently, RO-DBT considers it likely that a therapeutic relation-
ship is superficial, if by the 14th session, a therapist/client dyad has not had
multiple alliance-ruptures and repairs. When an alliance rupture is sus-
pected, RO-DBT therapists are taught to adopt a stance of relaxed, yet
engaged, curiosity in order to facilitate a repair. This typically involves
seven sequential steps:
1) Dropping the current agenda or topic being discussed (e.g., chain
analysis).
2) Taking the heat-off by briefly disengaging eye-contact. Most OC
individuals dislike being the center of attention (i.e., the lime-
light). Heat-off is a skill that involves briefly shifting ones attention
elsewhere in order to allow a hyper-threat sensitive OC client time
to self-regulate.
3) Signaling affection and cooperation by leaning back, taking a slow
deep breath, half smiling, and raising ones eyebrows. Raised eye-
brows (or eyebrow wags) are universal signals of liking and social-
safety.
4) Inquiring about the in-session change and encouraging candid
disclosure e.g. I noticed something just happened (describe
change), then Did you notice this too? Whats going on with you
right now?
5) Slowing the pace of the conversation, allowing time for the client to
reply to questions, reflecting back what is heard, and confirming
that the reflection was accurate.
6) Reinforcing candid self-disclosure (e.g., thanking them for the gift
of truth).
7) Confirming re-engagement by checking in with them before return-
ing back to the original agenda. It is important to keep repairs short
(less than 10 minutes) in order to reinforce self-disclosure (recall
that clients who over-control dislike the limelight).
Though life-threatening and therapeutic- alliance ruptures take prece-
dence when present; the third most important target in the RO-DBT
treatment hierarchy pertains to the reduction of maladaptive OC behaviors
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Table 2. OC BEHAVIORAL THEMES: PATH TO FLEXIBLE MIND

Maladaptive OC Theme Primary Social-Signaling Deficitand examples

Inhibited Emotional Refers to social-signaling deficits linked to emotional expression. E.g.


Expression inhibited, constrained, and frozen facial expressions, body movements, and
gestures or overly pro-social, phony, and insincere facial expressions and
gestures; very few people may know that they have an explosive temper or
high anxiety, may rarely spontaneously laugh; find it difficult to speak about
inner feelings or reveal vulnerability; may pout or use the silent treatment to
punish others when angry.
Hyper-Vigilant and Overly- Refers to social-signaling deficits stemming from OC bio-temperamental
Cautious predispositions for high threat sensitivity, low reward sensitivity, and high
detail-focused processing. E.g., tense-monotonic voice tone; guarded and
wary when entering new situations; frequent checking and re-checking of
safety cues despite evidence that all is well, avoiding risks that cannot be
controlled or planned in advance; hyper-attentive for discrepancies or
mistakes, anxiety may interfere with their abilities to hear what another
person is saying; obsessive about details, rarely genuinely amused or content,
serious about life; may frequently notice errors that other people miss; may
feel compelled to correct mistakes made by others; may rarely relax or seek
pleasure; believe life is hard.
Rigid and Rule-Governed Refers to social-signaling deficits resulting from compulsive needs for order
Behavior and structure. E.g. high moral certitudethere is a right and wrong way to
do things; will make self-sacrifices to care for others or to do the right
thing; strong desires to be correct; hyper-perfectionism; believe that there is
a set of rules and principles that one should always adhere to; compulsive
rehearsal, premeditation, and planning; compulsive approach-coping and
fixing; excessive persistence despite evidence that it will do harm; actions
motivated by social obligation and dutifulnessrather than anticipatory
pleasure; may work obsessively.
Aloof and Distant Refers to social-signaling deficits linked to low openness and conflict
Relationships avoidance. E.g. walking-away or abandonment is the preferred solution
during interpersonal conflict; having to be around others for long time
periods is exhausting or annoying; very few people may know who they
really are; feel detached or different from others; low social-connectedness is
not necessarily due to lack of contact with others; when challenged by
someone tend to immediately deny, dismiss, or dispute the feedback; may
rarely-apologize; may believe that love is phony or naive; may secretly believe
they are superior to others.
Envy and Bitterness Refers to social-signaling deficits linked to compulsive striving, high social
comparisons, and high dominance. E.g. not easily impressed; secretly
competitive; may feel unappreciated for self-sacrifices; may consider
themselves a cynic or a martyr; may believe that most things in life dont
work out; may do almost anything to get ahead; may be secretly proud of
their ability to tolerate pain or distress in order to achieve a goal; may see
self as too complex to ever be understood; may engage in harsh gossip and
revengeful acts; high resentment, resignation, and pessimism.

linked to five OC behavioral themes. These themes (see Table 2), specific
for OC problems, are used as a framework for structuring the identifica-
tion of individualized and behaviorally specific OC treatment targets. The
key in treatment targeting with OC is for the therapist to continually ask
themselves in-session: How might this type of social-signaling e.g. pout-
ing, looking away, flat affect, non-descript use of language, answering a
question with a questionimpact the formation of a strong social bond? or
Would this behavior make it more likely or less likely for a person
interacting with my client to want or desire to get to know them better?
Thus, treatment targeting and subsequent behavioral chain analyses in
RO-DBT prioritize changing problematic social-signaling deficits that func-
tion to reduce social-connectedness (e.g., turning-down help; silent treat-
ment) over problematic internal experiences (e.g., emotion dysregulation,
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distorted thinking; experiential avoidance). Individualized targets are


monitored daily on diary cards and updated regularly.
RO-DBT Skills Training
Radically Open-DBT skills training classes meet on average for 30
weekly sessionswith each class lasting approximately 2.5 hours. Table 3
provides an overview of the RO-DBT skills training lesson planincluding
those from standard DBT (Linehan, 1993b; 2014) that have been adapted
for OC problems (identified by * and italics). Next we review the core
theoretical principles underlying radical openness and describe some of
the new features in RO-DBT mindfulness skills. The RO-DBT treatment
manual provides detailed skills training instructor notes and key teaching
points for all of the RO-DBT skills listed in Table 3including user
friendly handouts/worksheets for clients (T.R. Lynch, in press).
CORE RADICAL OPENNESS
Radical openness represents the core philosophical principle and core
set of skills in RO-DBT. It is based on confluence of three overlapping
elements or capacities posited to characterize psychological health: open-
ness, flexibility, and social connectedness (with at least one other person).
As a state of mind, it entails a willingness to surrender prior preconcep-
tions about how the world should be in order to adapt to an ever-changing
environment. At its most extreme, radical openness involves actively
seeking the things one wants to avoid in order to learn. Radical openness
alerts us to areas in our life that may need to change while retaining an
appreciation for the fact that change is not always needed or optimal.
RO-DBT replaces core Zen principles in standard DBT with those
derived from Malamati-Suffism. The Malamatis are not so much interested
in the acceptance of reality or seeing what is without illusion (central
Zen principles), but rather they look to find fault within themselves and
question their self-centered desires for power, recognition or self-aggran-
dizement (Toussulis, 2012). Thus, radical openness involves purposeful
self-enquiry and the cultivation of healthy self-doubt. Importantly, radical
openness differs from radical acceptance taught as part of standard DBT
(Linehan, 1993a). Radical acceptance is letting go of fighting reality and
is the way to turn suffering that cannot be tolerated into pain that can be
tolerated (Linehan, 1993b, pg. 102), whereas radical openness challenges
our perceptions of reality. Indeed, radical openness posits that we are
unable to see things as they are, but instead that we see things as we are
because each of us carries perceptual and regulatory biases with us that
influence our ability to be receptive and to learn from unexpected or
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Table 3. AN OVERVIEW OF RO-DBT SKILLS TRAINING LESSONS

Lesson # Skills Taught

Lessons 1-2: Practicing Radical RO-Why be radically open? RO-Learning from Self-Enquiry, RO-Myths
Openness and Understanding of a Closed Mind, RO-Three Steps for Radically Open Living; RO-
Emotions Five Emotionally Relevant Cues, RO-Model of Emotions,
Lessons 3-4: Labelling Emotions and RO-Over-Controlled Myths about Emotions, RO-Emotions are there for
Understanding Over-Controlled a Reason, RO-Making sense of Emotional Reactions; RO-
Coping Understanding Over-controlled Coping, RO-Over-control can
become a Habit!
Lessons 5-6: OC States of Mind and RO-Mindfulness States of Mind; Fixed-Mind, Fatalistic-Mind, Flexible-
Radical Acceptance Mind; *standard DBT Letting go of Emotional Suffering; *standard
DBT Radical Acceptance skills1
Lessons 7-8: Changing Social RO-Change Social Behavior by Changing Physiology, RO-Open
Connectedness by Changing expression Trust Social Connectedness.
Physiology
Lessons 9-10: Mindfulness and Self- RO-Mindfulness What skills*standard DBT mindfulness observe
Enquiry skills; RO-Awareness Continuum and Outing-Oneself describe
skills; RO-participate without planning skills. RO-Mindfulness
How skillsRO-with awareness of judgments, RO-with self-
enquiry, *standard DBT one-mindfully skills, and *standard DBT
effectively.
Lessons 11-12: Celebrating Novelty and RO-Engaging in Novel Behavior, RO-Flexible-Mind VARIES2 in order
Going Opposite to Seriousness to learn new things,; standard DBT opposite action skills; RO-Going
Opposite to Seriousnessthe Art of Non-Productivity & Being a
little bit Silly
Lessons 13-14: Learning from Corrective RO-Learning from Corrective Feedback using Flexible-Mind ADOPTS;
Feedback RO-Accept or Decline Feedback12 Questions.
Lessons 15-16: Social-Signaling Impacts RO-Social-Signaling Push-Backs and Dont Hurt Me; RO-Myths
Relationships about Interpersonal Relationships; *standard DBT Goals of
interpersonal effectiveness and DEAR MAN-GIVE FAST skills.
Lessons 17-18: Signaling Empathy and RO-Social-Signaling Empathy and Validation; RO-Seven Ways to Signal
Validation Empathy; RO-Flexible-Mind Validates.
Lessons 19-213: Repetition of RO-States Repeat RO-States of Mind and RO-Mindfulness What and How
of Mind and Mindfulness Skills skillsincluding *standard DBT observe and one-mindful skills.
Lessons 22-23: Learning How to Signal RO-Intimacy Thermometer; RO-Flexible-Mind ALLOWs one to
Trust and Establish Social enhance social connectedness; RO-Match 1 skills; RO-Levels of
Connectedness Relationship Intimacy.
Lessons 24-263: Understanding Envy, RO-understands Envy, Resentment, Bitterness, and Revenge; RO-
Resentment, Bitterness, and Revenge Flexible-Mind DAREs to let go of envy; RO-Flexible-Mind is
LIGHT when targeting bitterness.
Lessons 27-28: Learning How to Forgive RO- What is forgiveness? RO-learning to grieve, RO-Flexible-Mind has
the HEART to forgive.
Lessons 29-30: Social-Safety Induction RO-Loving-Kindness Meditation skillsactivating social-safety mood
Using Loving-Kindness-Meditation states; RO-Integration Week4.
and Summing it All Up

Note1: standard DBT skills can be identified by an * and italicsthey include; standard DBT Letting
go of Emotional Suffering; standard DBT radical acceptance skills; standard DBT observe and one-
mindfully skills; standard DBT effectively; standard DBT opposite action skills; standard DBT Goals of
interpersonal effectiveness and DEAR MAN-GIVE FAST skillsall of which have been modified to
some extent for OC problems.
Note2: Similar to standard DBT, acronyms are used as mnemonic aids in RO-DBT. For example, in
Lessons 27-28: Flexible-Mind has HEART, Learning How to Forgive, each letter of the acronym
HEART refers to a specific set of skills; H stands for the skill of identifying the past Hurt; E stands
for the skill of locating ones Edge that is keeping you stuck in the past; A stands for Acknowledge that
forgiveness is a choice, R stands for Reclaim your life by grieving the your loss and practicing
forgiveness; and T stands for the importance of passing-on Thankfulness.
Note3: Lessons 19-21 are repetitions of Lessons 5-6 & 9-10 compressed into three weeks. Lessons
24-26 are expected to take three weeks.
Note4: Integration Week is intended to provide the space for instructors and clients to pull it all
together, be creative, and/or review core skills in order to deepen their practice of radical openness.

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disconfirming information. This way of behaving also contrasts with the


concept of wise mind in standard DBT that emphasizes the value of
intuitive knowledge, the possibility of fundamentally knowing something
as true or valid, and posits inner knowing as almost always quiet and to
involve a sense of peace (Linehan, 1993b, p. 66). From an RO-DBT
perspective, facts or truth can often be misleading partly because we
dont know what we dont know, things are constantly changing, and
there is a great deal of experience occurring outside of our conscious
awareness. Truth is considered real yet elusive e.g. If I know anything,
it is that I dont know everything and neither does anyone else (M. P.
Lynch, 2004; pg. 10). It is the pursuit of truth that mattersnot its
attainment. Radical openness requires willingness to doubt or question
intuition or inner conviction without falling apart.
The practice of radical openness involves three steps: 1) acknowledg-
ment of environmental stimuli that are disconfirming, unexpected, or
incongruous, 2) purposeful self-enquiry into habitual or automatic emo-
tion-based response tendencies by asking Is there something here to
learn? rather than automatically explaining, justifying, defending, ac-
cepting, regulating, re-appraising, distracting, or denying what is happen-
ing in order to feel better, and 3) flexibly responding by doing what is
needed to be effective in the moment in a manner that signals humility and
accounts for the needs of others (e.g., recognizing that what is effective
for oneselfmay not be effective for others; celebrating diversity; signaling
a willingness to learn from what the world has to offer; strive for perfec-
tion, but stop when feedback suggests that striving is counterproductive or
damaging a relationship).
RO-DBT Mindfulness Skills
Mindfulness skills in RO-DBT include new OC states of mind (Fixed-
Mind, Flexible-Mind, and Fatalistic-Mind) and new what and how
skills (i.e., Awareness Continuum and Outing-Oneself describe skills,
Participate without Planning skills; Self-Enquiry skills, and with
Awareness of Judgments skills). The new mindfulness states of mind in
RO-DBT represent common OC ways of copingthat can be both
adaptive and maladaptive depending on the circumstances. For OC indi-
viduals two states of mind are most common both of which are usually
maladaptive and occur secondary to disconfirming feedback and/or when
confronted with novelty. When challenged or uncertain, the most common
OC response is usually to search for a way to minimize, dismiss, or
disconfirm feedback in order to maintain a sense of control and order. This
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style of behaving in RO-DBT is referred to as fixed mind. Fixed mind is a


problem because it says change is unnecessary because I already know the
answer. The dialectic opposite of fixed mind is fatalistic mind. Whereas
fixed mind involves rigid resistance and energetic opposition to change,
fatalistic mind involves giving-up overt attempts at resistance. Fatalistic
mind can be expressed by drawn out silences, bitterness, refusals to
participate, and/or sudden acquiescence or a literal suspension of goal-
directed behavior and shut-down. Fatalistic mind is a problem because it
removes personal responsibility by implicating that change is unnecessary
or impossible because there is no answer. Mindful awareness of these
states serves as important skill practice reminders. Flexible mind forms
the synthesis between fixed and fatalistic mind states: it involves being
radically open to the possibility of change in order to learn, without
rejecting ones past or falling apart. Importantly, although wise mind in
standard DBT and flexible mind in RO-DBT share some similar functions,
there are also important differences. For example, whereas wise mind
celebrates the importance of inner knowing and intuitive knowledge (see
Linehan, 1993b pg. 66), flexible mind celebrates self-enquiry and encour-
ages healthy self-doubt and compassionate challenges of our perceptions
of reality.
There are two new RO-DBT mindfulness What skills. The first is an
RO- describe skill known as the Awareness Continuum, which pro-
vides a structured means for a client who is over-controlled to practice
revealing inner feelings to another personwithout rehearsal or planning
in advance what one might say. It also allows practitioners an opportunity
to practice how to label and differentiate between thoughts, emotions/
feelings, sensations, and images. The second RO-DBT what skill is
referred to as Participating without Planning. This skill involves learning
how to passionately participate with others without compulsive rehearsal
or obsessive needs to get it right. Participating without planning practices
should be unpredictable (i.e., they begin without any form of forewarning
or orientation) and brief (i.e., 60 seconds in duration). For example, the
instructor without any forewarning suddenly begins to make a silly face,
wave their arms about, while saying; OK, everyone do what I do! Make a
funny face and wave your arms, like this! And this! (changing expression
while clucking and flapping like a chicken) Theres nobody here but us
chickens! Wow, look at me . . . Im speaking nonsense! Blah-Blah. Now say
it again. Blah-Blah! Say bloo-blip and blippity-bloop! OK, now say, blippity-
be-ba-blipty bloo! (pause with warm smile, eye contact all around and
eyebrows raised) Getting better, LETS GO LOUDER! Say, OHRAW!
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SAY OHRAWWW! SAY IT AGAIN. . .OOOHHHRAWWWW! OK, all


together now . . . LETS START SPEAKING GOBBLITY-GOOK WHILE
WAVING OUR ARMS! ITS A NEW LANGUAGE! Havent you heard?
Boo . . . boo . . . blickety-block and floppity-flow and mighty so-so! Instruc-
tors should end by clapping their hands in celebration and encourage the
class to give themselves a round of applause. Well done! OK, now sit
down and lets share our observations about our mindfulness practice. The
brief nature of the practice makes it less likely for self-consciousness to
arise and more likely for individual members to experience a sense of
positive connection or cohesion with the class as a wholethat generalizes
outside of the classroom with repeated practice. These practices are an
essential tool for teaching clients characterized by over-control how to
re-join the tribe.
There are two new RO-DBT mindfulness How skills. With Self-
Enquiry is the core RO-DBT how skill and the key for radically open
living. It involves actively seeking the things one wants to avoid or may find
uncomfortable in order to learn and the cultivation of a willingness to be
wrongwith an intention to change if needed. Self-enquiry celebrates
problems as opportunities for growthrather than obstacles preventing us
from living fully. The core premise underlying self-enquiry stems from two
observations: 1) we do not know everythingtherefore, we will make
mistakes, and 2) in order to learn from our mistakes, we must attend to our
error. Rather than seeking equanimity, wisdom, or a sense of peace,
self-enquiry helps us learn because there is no assumption that we already
know the answer. RO-DBT therapists must practice radical openness and
self-enquiry themselves in order to encourage clients to use self-enquiry
more deeply. For example, one therapist practiced outing themselves to
their client in order to illustrate how Fatalistic-Mind thinking thrives on
denial and self-deception by saying:
Though it is hard to admit . . . during an argument, say with my partner. . .
.sometimes I purposefully become less talkative or avoid eye contact in order
to punish them for not agreeing with me; that is, I pout. If the person Im
with asks me why I am not talking, I usually deny that I am being quiet, yet
deep down I know that I am purposefully choosing to talk less. What I find
amusing is that the more willing I am to concede to myself or the other
person that I am in Fatalistic-Mind, the harder it is for me to keep it up. I
have discovered that, for me, pouting can really only exist if I pretend its not
happening. Once I admit it; even just to myself; I find it difficult to maintain
because deliberate pouting is not how I want to behave or deal with conflict.
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My self-enquiry work around this has helped me live more fully according to
my values.
The willingness of the therapist to reveal weakness without falling apart or
harsh self-blame functioned to encourage the client to behave similarlyin
this case, the client revealed for the first time that he often secretly tried to
undermine others and sometimes lied to obtain a desired goal. The clients
self-disclosure of a previously well-guarded secret resulted in the iden-
tification of important treatment targets linked to envy and bitterness.
Outing ones personality quirks or weaknesses to another person goes
opposite to OC tendencies of masking inner feelingstherefore, the
importance of this when treating OC cannot be overstated. Plus, since
expressing vulnerability to others functions to enhance intimacy and
desires to affiliate, the practice of outing oneself when used in other
areas of life can become a powerful means for OC clients to rejoin the
tribe. Practicing self-enquiry is particularly useful whenever we find
ourselves strongly rejecting, defending against, or agreeing with feed-
back that we find challenging or unexpected. Self-enquiry begins by
asking: Is there something to learn here? Examples of self-enquiry
questions include:
Is it possible that my bodily tension means that I am not fully open to
the feedback? If yes or possible, then: What am I avoiding? Is there
something here to learn?
Do I find myself wanting to automatically explain, defend, or discount
the other persons feedback or what is happening? If yes or maybe, then:
Is this a sign that I may not be truly open?
Do I believe that further self-examination is unnecessary because I have
already worked out the problem, know the answer, or have done the
necessary self-work about the issue being discussed? If yes or maybe,
then: Is it possible that I am not willing to truly examine my personal
responses?
The second new how skill in RO-DBT mindfulness is Awareness of
Unhelpful Judgments. Our brains are hard-wired to evaluate the extent we
like or dislike what is happening to us each and every moment. Thus,
from an RO-DBT perspective we are always judging and our perceptual
biases influence our relationships and how we socially-signal. RO-DBT
encourages clients to use self-enquiry to learn how judgments impact
relationships and social-signaling. For example, by asking:
When I am self-critical or self-judgmental, how do I behave around
others? For example, do I hide my face, avoid eye contact, slump my
shoulders, and/or lower my head? Do I speak with a lower volume or
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Radically Open-DBT for Over-control: Signaling Matters

slower pace? Or do I tell others that I am overwhelmed and/or unable


to cope?
How does my self-critical social-signaling impact others? What might
my self-judgmental social-signals tell me about my desires or aspira-
tions? What am I trying to communicate when I behave in this way?
RO-DBT Skills Generalization: Building Bridges to Enhance
Social-Connectedness
In standard DBT, the function of enhancing skills generalization is
most frequently accomplished via the use of telephone skills coaching by
the individual therapist (see Linehan, 1993a). In general, OC clients are
less likely to utilize this mode. As one client characterized by over-control
explained I just dont do crisis. In our current RO-DBT multi-center
RCT (project REFRAMED) the majority of skills coaching involves
clients learning to celebrate success by text-messaging their therapist when
the use of an RO-skill worked or using text-messaging to practice
outing-themselves when they experience new insight or learning follow-
ing a practice of self-enquiry. In addition, RO-DBT encourages therapists
to invite families, partners, or caregivers to participate in treatment. The
RO-DBT treatment manual (T.R. Lynch, in press) includes RO-couple
therapy and RO-multi-family treatment protocols. Treatment strategies
with families, couples, and other important members of a clients social
network typically involve: 1) educating the family/partner/caregiver about
the RO-DBT neurobiosocial theory and linking this to the treatment
strategies being used with the client; 2) explicit training in core RO-DBT
skills to facilitate skills generalization; 3) modeling and encouraging dia-
lectical thinking, e.g., demonstrating that there can be more than one way
of thinking about something; and 4) encouraging the family/partner/
caregiver to embrace a spirit of radical openness and self-inquiry when
problems or challenges arise.
RO-DBT Consultation and Supervision: Practicing Radical
Openness Ourselves
Therapists using RO-DBT ideally build into their treatment program a
means to support therapists to practice radical openness themselves and
support them in effectively delivering the treatment. This most often
translates into a weekly therapist consultation team meeting. In RO-DBT
a consultation team meeting is highly recommended, but not required. The
rationale for making the consultation team optional is partly influenced by
the less severe crisis generating behavior seen among clients characterized
by over-control, as well as practical, since the majority of therapists treating
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over-controlled problems do not traditionally work in teams. Therapists


without teams are encouraged to find a means to re-create the function an
RO-consultation team (e.g., virtual teams; supervision). Consultation team
meetings serve several important functions, including reducing therapist
burnout, providing support for therapists, improving phenomenological
empathy for clients, and providing treatment planning guidance. Plus, a
major assumption in RO-DBT is that to help clients learn to be more open,
flexible, and socially connected, therapists must practice the same skills in
order to be able to model them to their clients. Thus, the consultation team
in RO-DBT is considered an important means by which therapists can
practice what they preach to their clients.

SUMMARY AND CONCLUSIONS


RO-DBT is a new transdiagnostic treatment targeting a spectrum of
disorders characterized by excessive inhibitory control or over-control.
Reflecting recent National Institute of Mental Health (NIMH) Research
Domain Criteria (RDoC) initiatives (http://www.nimh.nih.gov/research-
priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml), RO-DBT pos-
its that core genotypic/phenotypic differences between groups of disorders
often necessitate vastly different treatment approaches. The treatment
uniquely exploits bottom-up peripheral nervous system processes to reg-
ulate OC bio-temperamental perceptual and regulatory biases e.g. teach-
ing skills to stimulate a neural substrate associated with social-safety and
desires to affiliate (i.e., PNS-VVC). RO-DBT also introduces a unique
mechanism of therapeutic change by linking the communicative and facil-
itative functions of emotional expression to the formation of close social
bonds. This translates into novel social-signaling skills designed to enhance
social connectedness that take advantage of the mirror neuron system and
our natural tendencies to micro-mimic othersa key component differ-
entiating RO-DBT from other treatments. Finally, a central premise of
RO-DBT is that well-being requires receptivity and flexible adaptation to
changing environmental demands, as well as a capacity to form close
long-lasting relationships. This definition differentiates perceptual and
reactive factors from regulatory and control factors, while acknowledging
the relational nature of our species. Well-adjusted persons are able to be
open to disconfirming feedback, and modify their behavior, in a manner
that accounts for the needs of others, as a means of optimizing perfor-
mance.
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Radically Open-DBT for Over-control: Signaling Matters

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162
Treatment Acceptability Study of Walking
The Middle Path, a New DBT Skills
Module for Adolescents and their Families

JILL RATHUS, Ph.D.*


BEVIN CAMPBELL, Psy.D.*
ALEC MILLER, Psy.D.#
HEATHER SMITH, Ph.D.#
In light of dialectic behavioral therapys effectiveness in treating suicidal
adults, the treatment has been adapted for use in diverse clinical populations,
including adolescents who are suicidal and have multiple problem. Walking
the Middle Path is a new skill- training module that addresses specific
problems and skill deficits of adolescents and their families. The present
study evaluated the acceptability of Walking the Middle Path, in order to
establish a basis for further assessment of the modules effectiveness. Fifty
participants receiving DBT for adolescent were administered a Treatment
Acceptability Scale, a skills-rating scale and an open-ended, qualitative
assessment. Results indicated high ratings of acceptability. Middle Path skills
ranked highly among the DBT skills perceived as most helpful, with valida-
tion rated the most beneficial aspect of skills training.
The study provides preliminary support for inclusion of Middle Path in the
skills training component of DBT with adolescents and their caregivers.
Clinical implications of responses and the role of validation in improving
family functioning are discussed.

KEYWORDS: DBT; treatment acceptability; adolescent suicide

INTRODUCTION
Outcome research has repeatedly indicated that dialectical behavior
therapy (DBT) is effective in improving the quality of life and reducing
self-harm among individuals with borderline personality disorder (cf.,
Koerner & Dimeff, 2007; Robins & Chapman, 2004). Miller and Rathus

*Long Island University, C.W. Post Campus, Brookeville, NY; #Montefiore Medical Center,
Bronx, NY. Mailing address: Jill Rathus, Ph.D., Department of Psychology, LIU Post, 720 Northern
Boulevard, Brookville, N.Y. 11548. e-mail: jill.rathus@liu.edu
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

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(Miller et al., 1997; Miller, Rathus, & Linehan, 2007) developed a modified
version of DBT for adolescents who were suicidal and had multiple
problems. Dialectical behavior therapy for adolescents targets teens who
exhibit chronic emotional dysregulation and a pattern of impulsive and/or
risky behaviors.
Millers and Rathus modifications maintain the theoretical and struc-
tural underpinnings of DBT, while incorporating caregivers in the skill
groups, add family therapy sessions, simplify skills hand-outs sheets with
teen-relevant examples, and offer phone consultation to parents (Miller et
al., 1997). As the use of DBT with adolescents has increased, so has
evidence of the treatments effectiveness with this population (e.g., Gold-
stein, Axelson, Birmaher, Brent, 2007; Mehlum, Tormoen, Ramberg, et al.,
2014; Rathus & Miller, 2002).
Initial work with DBT in adolescent populations led to the observation
that adolescent clients and their caregivers exhibit unique dialectical
dilemmas (Rathus & Miller, 2000). In standard DBT, dialectical dilemmas
are conceptualized as behavioral patterns (typical of suicidal and BPD
patients) wherein an individual shifts between polarized positions (Line-
han, 1993). Alternating between extreme behaviors represents an attempt
to correct intense emotional dysregulation. However, because these ex-
treme behaviors tend instead to underregulate or overregulate emotions,
they can be understood as dialectical failures.
The adolescent-family specific dialectical dilemmas formulated by
Rathus and Miller (2000) are behavioral extremes frequently experienced
by parents of suicidal, multi-problem adolescents, as well as by the teens
themselves. While Linehans (1993) dialectical dilemmas are applicable to
this population, Rathus and Millers dilemmas highlight the unique inter-
action patterns of troubled adolescents and their families. The adolescent-
family dialectical dilemmas are 1) excessive leniency versus authoritarian
control, 2) pathologizing normative behaviors versus normalizing patho-
logical behaviors, and 3) fostering dependence versus forcing autonomy.
To target the behavioral patterns related to these dialectical dilemmas,
Rathus and Miller (2000) developed a fifth skills training module, walking
the middle path. In addition to teaching families about the adolescent-
family specific dialectical dilemmas, walking the middle path reviews the
concept of dialectics, which is both the philosophical basis of DBT and a
component of its core intervention strategies. Dialectics helps families
integrate multiple perspectives, think in a less black-and-white fashion,
and generate balanced, rather than extreme, solutions to the adolescent-
family dilemmas. Walking the middle path also highlights two skill areas
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that comprise the core dialectic of DBT: acceptance and change (Miller,
Rathus, and Linehan, 2007). Acceptance is targeted through validation
skills, while change is targeted through behavioral modification skills.
Validation is a central component of standard DBT; Linehans (1993)
biosocial theory of borderline personality disorder suggests that individu-
als with BPD are brought up in pervasively invalidating environments.
Linehan (1993) defined the invalidating environment as one in which
Communication of private experiences is met by erratic, inappropriate,
and extreme responses . . . . The expression of private experiences is not
validated; instead, it is often punished, and/or trivialized (p. 49). Miller,
Rathus, & Linehan (2007) have highlighted that invaliding environments
for teens may include (but are not limited to ) schools (i.e. teachers,
administrators), peers, coaches, therapists, and family members (i.e,. those
with whom they live as well as other relatives).When reared in an invali-
dating environment, an emotionally vulnerable child may come to doubt
her personal understanding of her experiences and learn that her feelings
are unacceptable to others, while failing to learn strategies to manage
emotions and solve problems. Invalidation is central to the development of
problematic behaviors and chronic emotional dysregulation, in part be-
cause it teaches a child that only extreme behaviors and emotions provoke
a desired response from the environment.
It stands to reason that suicidal, multi-problem, emotionally dysregu-
lated adolescents will also frequently be products of invalidating environ-
ments. Indeed, research has indicated that adolescents who perceive their
parents as uncaring or affectively unresponsive are at an increased risk for
suicidal ideation and behavior (King, Segal, Naylor, & Evans, 1993; Adam,
Keller, West, Larose, & Goszer, 1994). One difficulty in addressing the
sequelae of chronic invalidation in adolescent populations, in contrast to
adult patients, is that the adolescent patients are typically still residing in
the invalidating family environments (Woodberry, Miller, Glinski, Indik,
& Mitchell, 2002). Thus, to reduce the cycle of invalidation that occurs in
some of these families it is necessary to target the environment itself by
including families in skills training.
Walking the middle path also focuses on behavioral change strate-
gies. The specific topics include positive reinforcement, negative rein-
forcement, shaping, extinction, and punishment. In standard DBT,
these learning principles are integral to the treatment; the therapist
reinforces target-relevant adaptive behaviors in session, and uses chain
analysis, a complex, detailed functional analysis, to help both patient
and therapist understand what factors trigger and maintain maladaptive
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behaviors (Linehan, 1993). By teaching the entire family behavioral


modification techniques such as principals of reinforcement and shap-
ing, in addition to offering as-needed family sessions, there is a greater
likelihood of the adolescent and the parent generalizing adaptive skills
outside of the therapy office.
An increasing number of families have taken part in walking the
middle path, and is reflected in the growing research that uses Millers,
Rathuss, and Linehans (2007) protocol. These studies suggest that use
of this protocol with adolescents exhibiting suicidality, BPD features,
and/or other psychiatric disorders is associated with a reduction in
behavioral problems, self-injury, and emotional dysregulation (see
Groves et al., for review; Mehlum et al., 2014). Despite the increase in
its use, the specific contribution of walking the middle path has not
been examined.
The current investigation serves as a first step towards assessing the
impact of walking the middle path by evaluating its acceptability. The
concept of treatment acceptability grew out of Kazdins (1977) and Wolfs
(1978) work on social validity, which held that in addition to efficacy, new
treatments must also be examined in terms of social significance, appro-
priateness, and relevance. Treatment acceptability is a vital component of
treatment evaluation; as Wolf (1978) notes, if an intervention is effective
but disliked, consumers will be unlikely to use it.
There has been little exploration of the acceptability of adolescent
DBT. In a modified DBT program for adolescents with eating disorders,
Schneider et al. (2010) found high ratings of consumer satisfaction, with a
strong correlation between ratings of adolescent patients and their parents.
Goldstein, Alexson, Birmaher, and Brent (2007) included a treatment
satisfaction questionnaire in their research on adolescent DBT that yielded
high ratings of acceptability. Cooney, Davis, Thompson, et al., (2012,
November) assessed the acceptability of adolescent DBT to gauge the
feasibility of larger scale randomized control trials. Results indicated that
treatment completion and attendance rates were higher for adolescents in
DBT as compared to usual treatment, and that families found DBT
acceptable.
The aim of this study was to assess acceptability and perceived help-
fulness of walking the middle path to adolescents and parents, in order to
support a rationale for further evaluation of the modules effectiveness.
The study aimed also to illuminate which aspects of middle path partici-
pants found helpful; to this end a qualitative analysis was performed
regarding participants evaluations of the module.
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Treatment Acceptabilty Study

Table 1. DEMOGRAPHIC CHARACTERISTICS OF THE CURRENT SAMPLE

Number Percent
Gender
Female 39 78
Male 11 22
Age Group
Parent 27 54
Adolescent 23 46
Ethnicity
Hispanic 8 16
Non-Hispanic White 42 84

METHOD
PARTICIPANTS
Participants (N50) were recruited from three New York DBT pro-
gramstwo private practices in Long Island and Westchester and an
outpatient adolescent clinic at a hospital in the Bronx. Each site offered
comprehensive DBT, used Miller, Rathus and Linehans (2007) DBT
multi-family skills training protocol, and included walking the middle path
in the skills training. Participants included adolescent patients and par-
ents/caregivers who took part in skills training; all adolescent clients had
weekly individual DBT sessions. To receive treatment, clients at the two
private practices needed to exhibit at least three DSM-IV criteria for BPD.
At the hospital site, clients also needed to have one suicide attempt or
incident of non-suicidal self-injury in the six months prior to treatment.
Exclusion criteria at each site included psychotic disorder or primary
substance abuse diagnosis. Table 1 lists demographic characteristics. All
participants identified as Non-Hispanic White or Hispanic; all Hispanic
participants were from the hospital site.
MEASURES
Treatment Acceptability Scale
Questions on the Treatment Acceptability Scale scale (TAS) were
drawn from the Treatment Evaluation Inventory-Short Form ([TEI-SF]
Kelley, Heffer, Gresham, & Elliott, 1989), a condensed version of Kazdins
(1980) Treatment Evaluation Inventory (TEI). The TEI is one of the most
commonly used measures of treatment acceptability (Gage & Wilson,
2000). The TEISF is shorter and uses simpler language than the TEI
(Finn & Sladesczek, 2001). The TEI-SF has been found to be valid and
internally consistent (coefficient .85). As the TEI-SF was originally
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AMERICAN JOURNAL OF PSYCHOTHERAPY

designed to assess parents acceptance of interventions for children, ques-


tions were modified for the current study, with the words walking the
middle path replacing intervention. Questions were also drawn from
the Child and Adolescent Mental Health Satisfaction Scale (CAMHSSS;
Ayton, Mooney, Sillifant, Powls & Rasool, 2007). The CAMHSSS is an
internally consistent and reliable measure of treatment satisfaction (Co-
hens kappa of items range between .61.80). Additional TAS items,
devised by the investigators, asked participants to rate the middle path
module on its relevance, on how much they believed it would promote
behavioral change in their child or parent, and about how glad they were
that they took part in it.
All questions on the TAS were rewritten to be at a Flesch-Kincaid
fifth-grade reading level. Each item was rated on a five-point Likert
scale: Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree. The
scores of each item jointly yielded a single acceptability score, the
magnitude of which represents the participants rating of the accept-
ability of the module.
DBT Skills Rating Scale for Adolescents
Rathus & Miller (1995) developed the DBT Skills Rating Scale for
Adolescents (DBT-SRS) in order to assess perceived helpfulness of DBT
skills across all modules. Subjective ratings of helpfulness for individual
skills are assessed on a fivepoint Likert scale ranging from not at all
helpful to extremely helpful. Participants in the current study were
administered a revised version of the DBT-SRS, which included skills
taught in the walking the middle path module. The psychometric proper-
ties of the DBT-SRS are unknown.
Open-ended Assessment
To gather detailed information about which aspects of middle path
informed participantsevaluation of the module, open-ended questions
were administered, including: What did you like most about walking the
middle path and why? and In what way do you think middle path could
help you and your family?
PROCEDURES
A demographic form, the Treatment Acceptability Scale, was ad-
ministered and the open-ended assessment following completion of the
middle path module (the modules last for four to five weeks, with
groups meeting weekly for two hours). Once participants completed all
five skills training modules, they completed the DBT-SRS. All partici-
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Treatment Acceptabilty Study

pants in the current study completed the TAS and the qualitative
assessment, though a minority (N13) left treatment prior to complet-
ing all skills training modules, or declined further participation in the
study after completing the initial assessments, therefore, they did not
complete the DBT-SRS. The skills trainers at each site included at least
one doctoral-level clinician with specialized training in DBT. Cofacili-
tators were either doctoral-level clinicians or pre-doctoral trainees. All
group leaders participated in DBT consultation team meetings at their
respective sites.
TREATMENT FIDELITY
Data regarding treatment adherence was collected from a subsample
of sessionsthose conducted at the Long Island site. Group leader
self-report adherence measures (i.e., checklists based on the manuals
outlined content) indicated that across two middle path module pre-
sentations, group leaders covered the material as outlined in the mid
dle path protocol with 100% accuracy during one presentation of the
module, and with 88% accuracy on the second. Additionally, one of the
treatment developers was a group leader at the Long Island site. While
data regarding treatment adherence was not obtained from the Bronx
or Westchester sites, at both sites the group leaders were supervised by
a treatment developer of the middle path module.
QUALITATIVE ANALYSIS
Two coders, who had received training in DBT, reviewed de-identified
data from the open-ended assessments. Each coder independently made
notes on the themes and concepts that emerged from the data, following
a technique derived from Strauss and Corbin (1990). Together, the two
coders then created a coding manual that broke larger concepts into
smaller, definable categories. Coders focused on the general impact of the
module, as well as specific content participants identified. Frequency of
specific skill references was also recorded (Table 2).
The two coders independently sorted responses into the devised cate-
gories. Intercoder reliability was calculated for each category using
Cohens Kappa (Cohen, 1960). Kappa values for the categories ranged
from .47 to 1, with only two of the 15 categories obtaining Kappa values
of less than .60. Generally, inte-coder agreement was high, likely due to the
structured nature of the questions, which allowed responses to be classified
with little inference. Discrepancies in categorization were resolved through
discussion between coders, and the consensus classification was used.
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Table 2. FREQUENCIES AND PERCENTAGES OF SPECIFIC MIDDLE PATH


SKILL REFERENCES IN QUALITATIVE RESPONSES

All Adolescents Parents

% of Total % of Total % of Total


Participants N Responses N Responses N Responses
What did you like most?
Validation 20 49% 8 53% 12 46%
Dialectical dilemmas 6 15% 2 13% 4 15%
Dialectical thinking 3 7% 1 7% 2 8%
Positive reinforcement 1 2% 1 7% 0 0
Consequences 1 2% 0 0 1 4%

RESULTS
Descriptive statistics were calculated for each item on the TAS, and an
overall acceptability score was derived from the mean scores of the nine
items (see Table 3). The overall acceptability score (4.23) indicated that the
module was found to be acceptable; participants agreed or strongly agreed
that the module was useful, interesting, and applicable. A two-sample
independent group t-test was performed; no significant differences in
acceptability ratings of adolescent and parent participants were found.
Descriptive statistics were calculated for each skill on the DBT-SRS,
and items were ranked in order of perceived helpfulness (Table 4). For

Table 3. DESCRIPTIVE STATISTICS OF TREATMENT ACCEPTABILITY


RATINGS OF MIDDLE PATH MODULE

All Adolescents Parents

Participants Mean SD Mean SD Mean SD


Help the relationship 4.33 .55 4 .45 4.57 .50
Positive reaction 4.2 .70 4.91 .68 4.43 .63
Lead to better things 4.24 .66 4.14 .77 4.32 .55
Liked the skills 4.28 .54 4.18 .50 4.36 .56
Potential to help 4.20 .58 4.05 .70 4.46 .46
Glad I took part 4.36 .53 4.23 .53 4.46 .51
My child will change 3.97 .67 4.05 .69 3.91 .67
Module was interesting 4.08 .70 3.76 .77 4.32 .60
Skills address issues I face 4.40 .64 4.24 .70 4.54 .58
Overall acceptability 4.23 .13 4.61 .31 4.38 .19

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Table 4. DESCRIPTIVE STATISTICS FOR PERCEIVED HELPFULNESS RATINGS


ON DBT-SRS

All Participants Adolescents Parents

Skill Mean SD Mean SD Mean SD


Validation 4.68 .63 4.64 .50 4.71 .71
Wise mind 4.51 .56 4.4 .63 4.60 .50
Reinforcement 4.47 .79 4.57 .51 4.4 .92
Dialectical thinking 4.38 .65 4.29 .61 4.48 .69
Acting effectively 4.37 .65 4.23 .46 4.45 .75
Observe 4.35 .80 4.33 .61 4.41 .90
GIVE 4.35 .61 4.30 .48 4.38 .70
Dialectical behavior 4.34 .72 4.29 .61 4.43 .91
Self-reinforcement 4.32 .84 4.43 .65 4.25 .97
FAST 4.30 .64 4.31 .48 4.29 .72
Non-judgmentally 4.27 .61 4.27 .59 4.27 .63
DEAR MAN 4.27 .67 4.23 .73 4.30 .70
Pros and Cons 4.26 .74 4.42 .65 4.14 .79
Describe 4.25 .84 4.25 .70 4.24 .94
Participate 4.22 .89 4.33 .62 4.14 1.04
Willing 4.22 .73 4.25 .70 4.20 .77
Factors to consider 4.21 .74 4.08 .76 4.24 .73
ABC-Cope ahead 4.19 .74 4.33 .72 4.09 .73
Radical acceptance 4.17 .83 4.11 .69 4.32 .92
Current emotions 4.15 .87 4.14 .54 4.15 1.04
Extinction 4.15 .80 4 .68 4.26 .85
IMPROVE 4.09 .92 4.14 .66 4.09 1.06
PLEASE 4.08 .69 4 .55 4.13 .76
Mastery 4.05 .86 4.13 .64 4 .86
ACCEPTS 4.05 1.01 4.42 .65 3.80 1.12
Self-soothing 4.03 1.04 4.42 .65 3.82 1.18
Shaping 4.03 .82 3.79 .70 4.21 .85
One-mindfully 4 .81 4 .53 4 .91
Biosocial theory 4 .83 3.93 .70 4.09 .92
Model of emotions 4 .87 3.87 .83 4.05 .87
ABC-accumulate 4 .83 4.07 .70 3.91 .92
Consequences 4 .87 3.79 .70 4.16 .93
Acting opposite 3.92 .99 3.87 .95 3.95 1.05
DBT assumptions 3.83 .92 3.57 .65 3.95 1.05
Worry thoughts 3.69 .88 3.62 .77 3.76 .94
TIP 3.68 1.05 3.73 .59 3.67 1.28
Cheerleading 3.62 .87 3.62 .77 3.6 .94
Note. Middle Path skills are in bold.
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Table 5. CATEGORIES, FREQUENCY AND PERCENTAGE OF RESPONSES, AND


SAMPLE RESPONSES FOR WHAT DID YOU LIKE MOST?

Categories N % Kappa Sample response

Made me and family more effective/productive 8 20% M.92 It helped with the fighting in my house and we
find solutions to most problems quickly.
The skills are readily applicable to my life 5 12% 1 It is specific to the types of thoughts and
actions we have family issues with.
Helped me embrace multiple perspectives 5 12% .89 I liked how the module was all about seeing the
other seeing the other perspective in an issue,
because I had trouble with seeing that.
Has helped reduce conflict 5 12% 1 My husband and I were able to communicate
with each other better.
Helped in changing mine and/or others 4 10% .64 Discussing how to handle negative behaviors
behaviors and how to implement consequences.
Relationships are improved/Individuals feel 4 10% 1 The validation skills have provided benefits
better across the boardit is central to our
improved family rapport.
I learned the importance of validating oneself 4 10% 1 Self-validation . . . I thought about it all week.
(self-validation) Most people need to self-validate better.
Taught me something useful about parenting 3 7% .47 The typical/not typical piece gave me a new
an adolescent perspective. All her actions were reasons for
me to go Code Red.

adolescents, the top five most highly rated skills were validation, reinforce-
ment, wise mind, dialectical thinking, and acting effectively. For adults, the
top rated skills were validation, wise mind, reinforcement, dialectical
thinking, and acting effectively. For both groups, middle path skills
comprised three of the top five most highly rated skills. An independent
sample t-test was conducted on parent and adolescent ratings of perceived
helpfulness of middle path skills; no significant differences between ado-
lescent and parent ratings were found.
Forty-one responses were coded for the question, What did you like
most about walking the middle path and why? Thirty-one were coded for
the question In what way do you think Middle Path could help you and
your family? Tables 5 and 6 show the breakdown of frequency of
responses in each category, kappa ratings, and sample responses.
DISCUSSION
On the Treatment Acceptability Scale, eight of the nine items received
average ratings ranging from agreed to strongly agreed, indicating that
middle path was regarded by participants as helpful, interesting, and
relevant. Additionally, three of the five DBT skills rated most highly (of 27
total skills taught) in perceived helpfulness were from the middle path
module. Overall, the middle path skill of validation was rated by both
parents and adolescents as the most helpful.
Both parents and adolescents identified reducing conflict and making
relationships closer and warmer as benefits of practicing validation.
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Treatment Acceptabilty Study

Table 6. CATEGORIES, FREQUENCY AND PERCENTAGE OF RESPONSES, AND


SAMPLE RESPONSES FOR IN WHAT WAY DO YOU THINK IT
COULD HELP YOU AND/OR YOUR FAMILY?

Category N % Kappa Sample Responses

Improved communication/reduced 9 29% .74 Help us make communication more productive,


arguing less extreme and volatile.
Helps us get to resolution in 6 19% .76 Can allow us to more effectively reach
conflict compromises.
Improved family relationships 4 13% .84 Validating my spouse and kids allows them to
feel heard. It creates closer relationships.
Provided specific things to do and 4 13% .63 It is a specific skill set that sets the tone for
say (actionable skills) interpersonal contact and is more actionable
between participants than some other
modules.
Increased my ability to acknowledge 3 10% .47 Helps you to be aware there are always two
multiple perspectives perspectives.
Reduced my black and white 3 10% 1 I can learn how not to see the world as
thinking completely black and white.
Improved behaviors of others in my 2 6% 1 Behaviorism was very helpful for my son to
family break some old habits.

The following participant quotes are representative of the recurring theme


that validation improved families functioning:
I like learning how to validate others, especially my mom because it
prevents a disagreement from turning into an argument.
The validation skill has provided benefits across the boardit is central
to our improved family rapport.
[I like] the validation portion because sometimes I feel my mom judges
my emotions and now she doesnt dismiss how I feel.
Validation helps others feel like you really care about them.
My new found awareness has already made our relationship better.
Validation give and takesimply understanding, taking into consider-
ation how someone feels.
Validating my spouse and kids allows them to feel heard. It creates
closer relationships.
These responses support the sentiments of Miller et al. (2002): It has
been our experience that teaching families how to validate one another is
the most crucial interpersonal skill for improving their relationships.
(p. 578).
According to Fruzzetti and Schenk (2008), validation has a soothing
impact, reducing emotional dysregulation while invalidation escalates
arousal. They note that when individuals are emotionally aroused, they
demonstrate reduced cognitive capacity, and self-awareness and stability of
self-image is jeopardized. As a result, an invalidated individual has diffi-
culty with accurate self-expression, and is less likely to communicate
effectively and be understood by others. The result is a continued cycle of
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invalidation that further increases emotional arousal. Inevitably, this


heightened arousal leads to interpersonal conflict. Another outcome is
engagement in dysfunctional behaviors, such as self-harm, to attempt to
modulate ones emotions (a hallmark pattern of self-harming adolescents).
In contrast, when family members communicate understanding and en-
dorse the legitimacy of another family members feelings and experiences
(validation), emotional arousal is reduced. Self-expression becomes more
accurate, increasing the likelihood the individual will receive further
validation. The intensity of conflict is reduced, as are emotional dysregu-
lation and maladaptive behaviors. Individuals feel soothed, and relation-
ships become less averse. This process was summed up simply and
eloquently by one participant who stated, Validation . . . allows empathy,
and can shift energy from resistance to cooperation and understanding. It
opens up alternatives to conflict.
In addition to validation, the most highly rated of all DBT skills on the
DBT-SRS were from the middle path and mindfulness modules. One
change-oriented skill (reinforcement) was ranked in the top five. The
desirability of learning to use positive motivators to change behaviors of
self and others is not surprising given the frequent use of coercive and
punishing strategies to change behaviors in families entering treatment (cf.,
Barkley, Edwards, & Robin, 1999).
Three other skills focused on acceptance of self and of others (valida-
tion) and of reality as is (acting effectively, wise mind). These skill rankings
support Millers, Wymans, Hupperts, Glassmans and Rathuss (2000)
findings that adolescents rated acceptance-oriented skills as more helpful
than change-oriented skills in DBT-A. Miller and colleagues (2000) sug-
gested that the acceptance skills were new to the repertoires of suicidal
adolescents, who tend to avoid painful experiences and emotional states.
The qualitative data from the present study seem to support this notion;
many respondents discussed how validation in particular was a new
concept to them: And validation!! How helpful was this piece . . . I just
didnt know . . . didnt realize. Interestingly, the novelty of validation as a
behavioral skill was commented on not only by adolescent participants,
but also by parents as well, as demonstrated by this quote from a mother:
Sometimes I didnt even know how invalidating and judgmental my
responses to my daughter were. This module gave me an awareness! To catch
myself and then gave me the very tools to use to change.
The current study also replicated Miller and colleagues (2000) findings
that even the lowest-ranked DBT skills received mean ratings between
neutral and helpful; no skills received ratings in the somewhat unhelpful or
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Treatment Acceptabilty Study

very unhelpful range. As the authors of the previous study (2000) caution,
the ratings of helpfulness may be subject to demand characteristics. In the
current study, attempts were made to reduce demand characteristics by
having the primary investigator, rather than the group leader, administer
assessments when possible.
LIMITATIONS OF THE CURRENT STUDY
One methodological issue common to studies of treatment acceptabil-
ity is that ratings were only collected for participants who completed
middle path. Individuals who left treatment early may have had different
experiences with middle path or skills training in general. An additional
limitation is that this study evaluated the modules acceptability to partic-
ipants; researchers have noted that it is difficult to determine whether
subjective evaluations of acceptability correspond with actual behavior
(Hawkins, 1991). The degree to which approving of middle path skills led
to increased skill use and if skill use led to improvements in participants
lives are unknown. Qualitative data does lend support to the notion that
participating in middle path led to improved family functioning; however,
a systematic evaluation of post-middle path outcomes is required to draw
firm conclusions about the behavioral impact of the module.
Treatment adherence was assessed at only one of the three sites (Long
Island), and was assessed by facilitator self-report rather than by indepen-
dent observation. However, 78% of participants were from this site, and
the co-leader of this skills-training group was a developer of the middle
path module.
Finally, generalizability was limited because the participant sample was
predominately white and from an upper-middle class economic back-
ground. The small number of minority participants (who received treat-
ment at an inner-city hospital) makes it difficult to draw conclusions about
what, if any, role ethnicity and socio-economic status play in how accept-
able a participant finds middle path.
FUTURE RESEARCH AND CLINICAL IMPLICATIONS
Despite these limitations, the current study provides preliminary sup-
port for the use of middle path as part of Adolescent DBT skills training.
Pending the findings of upcoming randomized controlled trials on Ado-
lescent DBT by Marsha Linehan and colleagues (Collaborative Adolescent
Research on Emotions and Suicide [CARES]) and by Mehlum and col-
leagues (Mehlum et al., 2014), dismantling studies could examine the
specific contribution of middle path to the efficacy of DBT for adolescents.
In assessing the contribution of middle path, one avenue of inquiry
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AMERICAN JOURNAL OF PSYCHOTHERAPY

suggested by the current study is an examination of the relationship


between ratings of helpfulness and functional improvements. Miller and
colleagues (2000) have examined the relationship between adolescents
ratings of skill helpfulness and improvement in corresponding life problem
areas. Similarly, Neascui, Rizvi, and Linehan (2010) have examined the use
of standard DBT skills as a mediator of treatment outcomes. Both studies
suggest that perceptions of skill helpfulness and skill use correlate with or
mediate improvements in functioning.
The current study raises the question of whether perceived improve-
ment in family functioning attributed to middle path corresponds to a
reduction in adolescent self-harm and other dysfunctional behaviors.
Family functioning is considered a vital treatment target in DBT for
adolescents because problematic family interactions have been demon-
strated to heighten suicidal risk (see Woodberry, et al., 2002, for review).
Findings regarding the value participants placed on validation can
inform the work of clinicians who work with families, in- and outside of
DBT. For families who are highly conflictual and in which negative
emotional arousal is pervasive, teaching the skill of validation may be a
powerful tool for improving family functioning. Findings of the current
study support the inclusion of middle path skills in DBT with adolescents.
While results are preliminary and derived from nonexperimental research,
the high perceived helpfulness ratings of middle path skills suggests that
participants found them to be of unique value and utility.

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178
Dialectical Behavior Therapy for Suicidal
Latina Adolescents: Supplemental
Dialectical Corollaries and
Treatment Targets

MIGUELINA GERMAN, Ph.D.*


HEATHER L. SMITH, Ph.D.
CAMILA RIVERA-MORALES, M.A.
GARNETTA GONZALEZ, B.A.
LAUREN A. HALICZER, M.A.
CHLOE HAAZ, M.S.
ALEC L. MILLER, Psy.D.
The primary aim of this paper is to describe extreme behavioral patterns that
the authors have observed in treating Latina adolescents who are suicidal and
their parents within the framework of dialectical behavior therapy (DBT).
These extreme patterns, called dialectical corollaries, serve to supplement the
adolescent/family dialectical dilemmas described by Rathus and Miller
(2002) as part of dialectical behavior therapy for suicidal adolescents with
borderline personality features. The dialectical corollaries proposed are old
school versus new school and overprotecting versus underprotecting, and
they are described in-depth. We also identify specific treatment targets for
each corollary and discuss therapeutic techniques aimed at achieving a
synthesis between the polarities that characterize each corollary. Lastly, we
suggest clinical strategies to use when therapists reach a therapeutic impasse
with the parent-adolescent dyad (i.e., dialectical failures).

KEYWORDS: Latina adolescent; suicide attempt; treatment; culture;


trauma; parenting; Hispanic; dialectical behavior therapy

Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. Mailing address:
*Department of Pediatrics & Department of Psychiatry and Behavioral Sciences, Montefiore Medical
Center/Albert Einstein College of Medicine, 3307 Bainbridge Avenue, 1st Floor, Bronx, N.Y. 10467,
Bronx, NY 10467. e-mail: mgerman@montefiore.org
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

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INTRODUCTION
In 2011, the Youth Behavior Risk Surveillance System found that 21% of
Latina adolescent females seriously considered a suicide attempt (SA) during
the past 12 months and 14% had engaged in at least one suicide attempt
(Centers for Disease Control and Prevention). These SA rates were higher
than those for African-American (8.8%) and Caucasian-American adolescent
females (7.9%). At Montefiore Medical Centers Adolescent Depression and
Suicide Program in the Bronx, NY, the majority of patients are Latina
adolescents. Our team conducted studies with Latina adolescents, parents,
and treating clinicians with the goal of improving our treatment protocol for
this high-risk group (German, Gonzalez, & Rivera-Morales, 2013; German,
Haaz, Haliczer, Bauman, & Miller, 2013).
A promising treatment for Latina adolescents who are suicidal is
dialectical behavior therapy (DBT), an evidence-based treatment originally
developed for adults with borderline personality disorder (BPD) who were
chronically suicidal (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991;
Linehan et al., 2006; Van den Bosch & Verheul, 2007; Verheul et al.,
2003). Dialectical behavior therapy was adapted for use with teens by
Rathus and Miller (2002). Studies comparing DBT to treatment-as-usual
conditions have shown promising results in reducing deliberate self-harm
behavior, psychiatric hospitalizations, suicidal ideation, depression, hope-
lessness, and borderline personality disorder symptomatology (Mehlum et
al., 2014; Rathus & Miller, 2002).
Marsha Linehan (1993) proposed that individuals who engage in suicidal
and nonsuicidal self-injurious behaviors (NSSI) with a diagnosis of BPD often
resort to extreme behavioral patterns, which are referred to in DBT as
dialectical dilemmas. When these patterns occur, the individual shifts between
polarized behavioral extremes in an effort to regulate his or her emotional
state. However, these patterns are ineffective and often function to over or
under regulate the individuals emotions and behaviors, and are thus deemed
as dialectical failures. Accordingly, Linehan (1993) developed treatment
targets to find a synthesis between the extreme behavioral styles by decreasing
these maladaptive behaviors (e.g., active passivity, apparent competence,
self-invalidation) and increasing adaptive behaviors (e.g., active problem
solving, effectively asking for help, and self-validation). See Linehan (1993) for
a full review of the original DBT dialectical dilemmas.
In working with adolescents who have multiple problems and BPD
features, Miller, Rathus, and Linehan (2007) described additional extreme
behavioral patterns that were transactional in nature and occurred
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DBT for Suicidal Latina Adolescents

between the adolescent and his or her environment. They identified three
dialectical dilemmas specific to working with adolescents and their parents
(i.e., excessive leniency versus authoritarian control, normalizing patho-
logical behaviors versus pathologizing normative behavior, and fostering
dependence versus forcing autonomy). These dialectical dilemmas have
been helpful to conceptualize adolescents and their parents problematic
behavioral patterns and to further formulate appropriate treatment targets.
Based on our research findings and clinical observations of Latina
adolescents and families, the current authors expand upon the existing
adolescent dialectical dilemmas by proposing supplemental dialectical cor-
ollaries frequently observed in Latino families. We first review the existing
adolescent/family dialectical dilemmas, and then discuss the dialectical
corollaries. Our goals are to provide additional interpretations of the
adolescent dilemmas to foster a better understanding of the extreme
behavioral patterns that can manifest in Latino families and better inform
our treatment targets and strategies.
BRIEF REVIEW OF ADOLESCENT DIALECTICAL DILEMMAS1
EXCESSIVE LENIENCY VERSUS AUTHORITARIAN CONTROL
Parents2 often waver between two extremes in this dilemma. Excessive
leniency refers to parents being overly permissive by making too few
behavioral demands on their teens. Authoritarian control refers to the
oppositeparents being too punitive. An example of excessive leniency is
when parents do not enforce consequences for their daughter skipping
classes because they believe that she may engage in self-harm behaviors if
she receives a consequence. Therefore, parents may be left feeling resent-
ful, powerless, confused or guilty as they believe that their parenting
behavior isnt in line with their personal values. In this example, as time
passes and the parents lack of enforcing appropriate consequences con-
tinues, the adolescents emotional and behavioral sequelae often intensify
(e.g., she now cuts school more frequently, is failing all of her high school
classes, and is violating curfew).
Eventually, this extreme behavior typically crosses the parents limits
and may result in a strong behavioral response to control their adolescents
1
For a full review of these dilemmas and their treatment targets see Miller, Rathus, & Linehan
(2007).
2
While the focus of this paper involves Latina adolescents and their parents, we have observed that
vacillations in extreme behavior can occur in persons other than just the parents. In fact, these
dilemmas can occur between two parents, between the teen and other caregivers, therapists, coaches,
as well as within the teen him/herself.

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other egregious behaviors. Parents may then oscillate to the authoritarian


pole (e.g., parents may ground the adolescent for the entire school year),
regardless of their anxiety about worsening their teens self-harm behav-
iors. The authoritarian response may induce hopelessness in the adolescent
and often results in the adolescent giving up and reengaging in extreme
high risk behaviors (e.g., NSSI).
NORMALIZING PATHOLOGICAL BEHAVIOR VERSUS PATHOLOGIZING NORMATIVE
BEHAVIOR
This dilemma involves parents becoming desensitized, overlooking or
minimizing their adolescents high risk behaviors (e.g., self-injury, abusing
alcohol, drunk driving) while pathologizing or becoming overly focused on
their adolescents less extreme or developmentally normative behaviors
(e.g., questioning authority, occasionally cutting a class, experimenting
with marijuana, etc.). In this dialectical dilemma, it is challenging for
parents and adolescents to identify what is normal versus abnormal
adolescent behaviors. Often times parents judgments have been distorted
by past experiences in which their adolescent attempted suicide or was
hospitalized psychiatrically. As a result, their parental compass becomes
askew and they often need help to make non-mood-dependent parenting
decisions. Parents are confronted with combating desensitization to harm-
ful adolescent behaviors and appropriately attending to them.
FOSTERING DEPENDENCE VERSUS FORCING AUTONOMY
Fostering dependence refers to parents engaging in behaviors that stifle the
adolescents natural movement towards autonomy. Parental behaviors that
foster dependence (e.g., excessive caretaking, not allowing their seventeen year
old to date) often stem from parents fears that allowing independence would
inevitably result in reduced protection of their emotionally vulnerable adoles-
cent from dangerous outcomes (e.g., another suicide attempt). In contrast,
forcing autonomy refers to an abrupt change in parental expectations and
behaviors that pushes the adolescent to behave and function independently
with little to no adult guidance. Parents may dramatically loosen or sever ties
with their adolescent, expecting her to make decisions about such things as
therapy, school, and prescription drug use. Parenting behaviors that force
autonomy may result from the parents feeling hopeless, exasperated, or
burnt-out in response to the adolescents on-going problematic behaviors or
they may be a function of an accumulation of the parents preexisting
overburdened family system. Parents may vacillate from one extreme to the
other. For example, parents may not allow their daughter to date until she is
eighteen; however, upon learning that she has become pregnant the parents
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may then kick her out of the house demanding that she now support herself
and her unborn child.
DIALECTICAL COROLLARIES SPECIFIC TO LATINO ADOLESCENTS AND FAMILIES
Examination and discussion of our research findings and clinical
experiences with Latino families resulted in the formulation of two addi-
tional extreme behavioral patterns; we refer to these as dialectical corollar-
ies. These dialectical corollaries expand on the aforementioned adolescent/
family dialectical dilemmas specifically for Latina adolescents and families
and provide further interpretations of the extreme behavioral patterns.
The dialectical corollaries include: 1) old school versus new school and 2)
overprotecting versus underprotecting.
We propose that old school versus new school is rooted in cultural and
generational factors that possibly contribute to why some Latina adoles-
cents, especially those whose families recently immigrated to the United
States, engage in suicidal behaviors over time. Overprotecting versus un-
derprotecting is linked to Latino parents who have experienced past abuse
or life-threatening extreme adverse events. We propose that parental
exposure to such events has critical consequences for their parenting
behaviors (German et al., 2013a). Below is a detailed description of these
new dialectical corollaries, clinical examples, treatment targets, and rec-
ommended therapeutic techniques to more effectively target change in
Latina suicidal adolescents and their families.
DIALECTICAL COROLLARY #1: OLD SCHOOL VERSUS NEW
SCHOOL
Old school refers to an extreme parenting style in which parents have
a rigid and inflexible adherence to the norms by which they were raised,
typically stemming from their country of origin. These norms include
expectations about age-appropriate behaviors, values, parenting practices,
and parent-child interactions. Even when Latino parents were raised in the
U.S.A., they often adhere strictly to the norms of their immigrant parents3.
Previous research has shown that traditional Latino families have some
norms about parenting practices, parent-child interactions, and values that
differ from U.S. norms. For example, Latino children are expected to
exhibit high degrees of control over their behaviors, particularly in public,
and normative parental discipline practices often include the use of
physical restraint or corporal punishment (Barker, Cook, & Borrego, 2010;
3
We recognize that norms are not only influenced by culture but also by the specific era and
neighborhood context in which parents were raised.

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Calzada, 2010). Researchers have also found Latino families more strongly
emphasize adolescents duty to take care of younger siblings compared to
Caucasian families (Fuligni & Pedersen, 2002). One cultural value that
holds great magnitude in Latino families is respeto (i.e., respect). In
general, the value of respeto places a greater emphasis on obedience
compared to the American value of respect (Andres-Hyman, Ortiz,
Anez, Paris, & Davidson, 2006).
Clearly, it is important for clinicians to assess the extent to which the
Latino parents they work with adhere to these traditional norms and to not
make assumptions about parents values and behaviors. The research
conducted in our clinic with our Latino population has highlighted the
importance placed on the value of respeto in the parent-adolescent rela-
tionship (German et al., 2013a). Specifically, we observed that adolescents
were taught not to question, argue, or negotiate with their parents given
that this manner of interaction was deemed disrespectful when the parents
were growing up. For parents who adhere to these old-school Latino
norms, violation of these expectations by their teenagers is perceived as
deviant within the family system, unacceptable to the parents and ex-
tended family members, and perceived as potentially dangerous by the
parents especially if families live in high-crime neighborhoods.
The old-school pole may also involve significant influence from ex-
tended family members. Some Latino parents report getting criticized for
not being able to properly control their adolescents behavior or for having
their teenager receive mental health treatment. Parents consequently re-
port feeling shamed by their extended family. This judgment often leads
parents to keep their parenting struggles to themselves and/or to not
participate in their adolescents treatment. As such, deviation from old
school values may result in the Latino parents development of cognitive
distortions of themselves as weak or a failure.
We propose that strict adherence to the old-school pole may be one
contributing factor in the development of the dialectical behavior pattern
called authoritarian control. As noted previously, parents that manifest this
extreme parenting behavior stifle their adolescents increasing desire for
autonomy, and apply excessive punishments or other methods to exert
control. Based on clinical research (German et al., 2013a, 2013b), we find
that parents of suicidal, Latina adolescents often limit their teens auton-
omy before they started engaging in self-harm behavior (e.g., many of our
Latina adolescents reported being unable to participate in after-school
activities, go to the park or store after school with friends, attend non-
family parties, or date). Latino parents often expressed the belief that their
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parenting behaviors were normative, considering what was typical of the


time and place they were raised. Researchers have reported that in Puerto
Rico, the Dominican Republic, and other Latino countries from which the
families in our program immigrated, alternative social structures and
practices enabled adolescents to socialize with peers (i.e., large extended
family networks); yet in the process of immigrating to the U.S.A., these
networks often were lost (Kulberg et al., 2010; Pena et al., 2011).
New school sits opposite old school in this dialectical corollary, and
refers to a rigid adherence to the current era and the dominant cultures
norms, values, parenting practices, and parent-child interactions. Latina
adolescents in our program typically fall at this end of the continuum.
Whereas the old-school pole involves the influence of extended family mem-
bers, the new-school pole involves influence from peers, teachers, and the
media in the U.S.A. Latina teenagers who attend American schools have more
exposure to and contact with the social mores of dominant culture compared
to their parents, who may continue to have much less exposure. In contrast to
the traditional Latino norms described previously, normative behaviors for
teenagers in America include a mild-to-moderate degree of negotiations with
parents, and a parental tolerance for increased argumentativeness, dating,
attending parties and sleepovers (Steinberg, 2005).
Latina adolescents within our studies often compared their lives to that
of their peers, many of whom were also Latina but came from more
acculturated families in which they were granted more autonomy (German
et al., 2013a). Latina teens often expressed that their parents should
allow them more liberties (e.g., attend parties with peers, have the same
[later] curfew as peers, etc.) When adolescents were not granted these
privileges, they often felt they had the right to question and repeatedly
negotiate with their parents, as they had observed these interactions
between their friends and their parents. Consequently, many of our Latina
teens would engage in these restricted and forbidden behaviors (such as
dating) in secret. We propose that this friction in beliefs and values lead
parents and adolescents to both feel disrespected and invalidated, thereby
increasing their levels of parent-teen conflict. Over a period of months or
even years, this conflict became chronic. The resulting tension, coupled
with the adolescents deficits in emotion regulation, was found to fre-
quently precipitate the teens suicidal behaviors as a means to temporarily
escape their uncomfortable negative emotional states. This behavior often
further reinforced the polarization between parents and their adolescents,
frequently causing the frightened parents to adopt an even stricter parent-
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ing regimen. Therefore, this old school manifestation exists as both a


precipitant and consequence of the adolescents suicidal behaviors.
Clinicians sometimes inadvertently enter into these polarities as well.
Many of our Latina adolescents disobeyed their parents strict orders in
order to conform to the new school norms. While keeping such violations
from their parents, they would disclose their behaviors to their clinicians
(German et al., 2013b). In turn, some clinicians described how they
developed a secret keeper role (i.e., trying to maintain the therapeutic
relationship and the adolescents confidentiality by withholding informa-
tion from parents, yet attempting to attend to parental concerns and
improve parent-adolescent communication). This dilemma was often fur-
ther complicated by clinicians feeling pulled to one end or the other of the
old school versus new school continuum due to their own generational and
cultural background.
Based on standard adolescent DBT protocol (Miller et al., 2007),
clinicians understandably spend more time listening to and validating the
adolescents view in individual sessions. Therefore, the therapist may feel
more empathic and prone to reinforce the adolescents new school ways.
The clinician must be careful to honor the old school ways and validate
the parents concerns when working towards a synthesis to resolve conflict
between the parents and adolescent; otherwise, parents may feel invali-
dated. This sense of parental invalidation may further strengthen their
polarized positions, often resulting in a therapeutic impasse.
OLD SCHOOL VERSUS NEW SCHOOL TREATMENT TARGETS: INCORPORATING
ASPECTS OF BOTH CULTURES
The treatment target for old school versus new school entails helping
parents and adolescents incorporate aspects of both cultures by increasing
validation and dialectical thinking.
Clinician Strategies for Parents
Clinicians should conduct at least one collateral session that focuses on
strengthening rapport with the parents. While it may start with parental
concerns about their teenager, the focus should shift to a discussion and
validation of the parents childhood experience. Clinicians should assess,
attempt to understand, and validate the advantages of the old school ways.
For instance, respeto emphasizes obedience and has been linked to raising
children who are perceived by parents and extended family as being bien
educado (i.e., well-mannered). Children adhering to these cultural ideals
exhibit behaviors such as not interrupting adults without saying excuse
me, having a polite disposition, and accepting parental decisions with
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little to no arguing. Latino parents who have children who are bien educado
are considered to be good parents by extended family members (Pena et
al., 2011). They receive positive reports from teachers regarding their
childs comportment at school, and worry less about their adolescents
getting into trouble for challenging authority, such as the police (Fuligni,
Witkow, & Garcia, 2005). Validating the positive qualities of these old
school ways will strengthen the clinicians alliance with parents.
After the clinician senses that the parent feels more understood and
validated, the clinician should discuss the potential disadvantages of the old
school ways. For example, many Latino parents in our clinic believe admin-
istering physical punishment with a belt or shoe is a normative parenting
practice because this was used when they grew up. However, presently, in
many parts of the United States (such as New York State), corporal punish-
ment (i.e., striking a child with an object and leaving a mark) is defined as
excessive, and state law requires the clinician to report such incidents to child
protective services. Thus, while corporal punishment may be intended to
instill respeto or decrease child misbehavior, it can have adverse consequences
for both parents and teen (e.g., child welfare agencies conducting investiga-
tions). Clinicians can validate the parents desire to raise a well-mannered,
respectful child, while highlighting that the parenting behavior itself is not
effective in this current cultural environment.
In order to help parents validate their adolescents experience, we
recommend clinicians prompt parents to reflect on how they felt as
teenagers when they perceived their parents to be overly restrictive. This
dialogue helps to increase parents mindfulness by helping them draw
parallels between how they felt in the past and how their adolescent
currently feels. To elicit a more empathic response toward their adoles-
cent, encourage parents to reflect on their own teenage years and how their
parents excessive restrictiveness may have negatively impacted relation-
ships. It is also important to encourage parents to consider what it must be
like for their teenager to struggle with multiple sets of cultural norms.
Highlighting this intergenerational pattern and the challenges of living
within two cultures can foster dialectical thinking. Clinicians should help
parents find the overlap between old school and new school parenting
approaches, hopefully translating to a synthesis. For example, an initial
middle path solution may be to allow their adolescent to earn privileges;
the teen may spend time with their peers after school as long as she
maintains a certain grade point average and keeps to a curfew for one
month. Assuming this is successful, the clinician can work with the dyad to
negotiate further compromises. These strategies are aimed at building a
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trustful alliance between the clinician and parent, which is key to support-
ing the adolescents treatment.
Clinician Strategies for Adolescents
Similar to the strategies used with parents, it is important for clinicians
to begin by gaining a location perspective of the adolescents to fully
understand their current experiences. Clinicians should start by acknowl-
edging and validating the advantages of the new school ways (e.g., learning
to be more independent prepares teens for adulthood, dating helps teens
develop relationship skills). Then clinicians can explore the potential cons
associated with remaining on this pole and also discuss the potential pros
and cons of the old school ways. The clinician should help the adolescent
identify the type of relationship that she desires with her parents and
describe how maintaining behaviors consistent with only new school ways
is not in line with achieving this goal. The adolescent is encouraged to
empathically consider her parents thoughts and feelings (e.g., how her
parents may feel when she dismisses their house rules) while she is focusing
on achieving her own goals (e.g., later curfew). Additionally, it is helpful to
increase the adolescents empathy in considering her parents challenges of
living in a new place with a different set of cultural values and norms.
Ultimately, these strategies are intended to help new school teens and old
school parents find a middle path and improve their relationship. [See
Table 1 for a summary of these strategies.]
DIALECTICAL COROLLARY #2: OVERPROTECTING VERSUS
UNDERPROTECTING
Both overprotecting and underprotecting poles appear to be related to
a subset of Latino parents who had exposure to abuse or near death
experiences that had critical consequences for their parenting behaviors.
We use the phrase history of trauma to indicate experiences of sexual,
physical, or emotional abuse or threat of a near-death experience or serious
injury when the parents themselves were children or adolescents. These
distressing experiences may have resulted in the development of trauma
symptoms, which in turn may have shaped their perceptions of the world
as unsafe or unfair and prompted the development of one of these two
extreme patterns of cognitive and behavioral responses.
Overprotecting refers to an extreme style in which parents maintain a
rigid and inflexible adherence to the notion that the world is an unsafe and
dangerous place. This notion informs the overprotecting parents percep-
tions that granting their adolescent more autonomy or freedom to explore
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Table 1. DIALECTICAL COROLLARY: OLD SCHOOL VERSUS NEW SCHOOL

Clinician techniques for Clinician techniques for


Treatment Target parents adolescents

Help parents and Assessment and validation of Assessment and validation of


adolescents to parents past experiences teens current experiences
incorporate Explore pros and cons of Explore pros and cons of
aspects of both old school norms new school ways
cultures Explore pros and cons of Explore pros and cons of
new school norms old school ways
Increase mindfulness of Elicit the type of behaviors
thoughts and feelings about and relationship adolescents
the negative impact of the want from their parent in
cons of old school norms on the present
past relationship with Increase mindfulness of
parents thoughts and feelings about
Increase perspective taking parent-teen relationship
skills on teens current Increase perspective-taking
experiences navigating old skills on parents experience
school and new school of having to navigate old
norms school and new school
Elicit current goals for norms
relationship with teen Increase validation of
Increase validation of teens parents
Help parent negotiate Increase interpersonal
incremental steps toward effectiveness skills
granting teen autonomy Help teen negotiate
incremental steps toward
gaining autonomy from
parent

the outside world is potentially life-threatening. This often stems from the
parents history of trauma. These parents become overwhelmed by feelings
of intense worry and consequently are very restrictive in their provision of
what is allowed versus what is not allowed in terms of their adolescents
behavior. They also often cite their own experience of trauma as evi-
dence or justification of their overprotecting parenting behaviors. The
adolescents failure to comply with these stringent rules typically result in
the excessive punishment seen in the original dialectical parenting pattern
of authoritarian control.
Overprotecting parents tend to be unresponsive and sometimes defen-
sive toward clinicians efforts to introduce supervised, normative activities
into the adolescents life. For example, a clinician may prompt overpro-
tecting parents to consider compromising with the adolescent by allowing
her to spend time with friends after school as long as an adult supervises
them. Parents may still insist that this is an unacceptable request because
they cannot trust any non-familial adult to provide appropriate supervision
(e.g., the parents refuse to permit the adolescent to join the school track
team). Parents that retain this overprotective stance do not consider their
concerns to be disproportionate to the risk involved; consequently, they
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may feel invalidated by the clinicians and adolescents attempts to nego-


tiate. Accordingly, these parents find it difficult to implement the specific
DBT skills of validation and perspective taking. We propose that parents
sense of ubiquitous danger may be triggering them to respond in this
unreceptive and inflexible manner. On this end of the continuum, parents
view their adolescent as vulnerable and lacking the capacity to keep
themselves safe.
Opposite the overprotecting pole exists the underprotecting pole,
which refers to an extreme view of the world as being inherently unfair and
unjust. Parents at this extreme often ruminate about their difficult child-
hoods, incessantly focusing on their own suffering and pain, and they tend
to compare their past anguish and own painful memories of abusive or
even traumatic experiences to those of their currently suicidal adolescent.
Social psychologists describe this process as downward social comparison
in which individuals in unfortunate circumstances attempt to enhance their
subjective well-being through comparison with seemingly less fortunate
others (Wills, 1981). These underprotecting parents consequently engage
in minimization and invalidation of their teen by considering their adoles-
cents life to be not as bad, and perhaps even notably better than their
own childhood. They often explicitly verbalize these thoughts to their
adolescent and the treating clinician. Statements such as shes ungrateful
for her better life, or she doesnt get the sacrifice Ive had to make to
raise her are typical among this subset of parents. In this scenario, the
adolescent appears to serve as a constant reminder or symbol of an unfair
world or of the parents past abusive relationships. This pervasive invali-
dation of the teen often leads the teenager to shut down, feel misunder-
stood, and creates unjustified feelings of shame, self-invalidation, and
increasing emotional and behavioral dysregulation.
Underprotection may be manifested by the parents minimization of the
danger surrounding their adolescents current suicidal ideation and past
suicidal behaviors. Even with the knowledge of their adolescents previous
attempts to overdose or engage in nonsuicidal self-injurious behaviors, parents
at this pole may not take the precautionary steps as directed by the clinician
to keep their adolescent safe by locking up medications and sharp objects.
Underprotection may also involve parental refusal (or minimal or ambivalent)
participation in the adolescents treatment.
Another aspect of this dialectical corollary includes parents burdening
their adolescent with adult-like responsibilities that often appear similar to
the dialectical dilemma forcing autonomy. Rathus and Miller (2000) posit
that parents at the forcing autonomy pole sever or loosen ties with their
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adolescent because they feel either overwhelmed by their teens suicidal


behaviors or they want to push their teen to mature more quickly. We
hypothesize that parents who underprotect engage in forcing-autonomy
type behaviors with their teen because they are motivated by their own
extreme childhood experiences of abuse or trauma. For example, at the
underprotecting pole, parents burden their adolescents with duties that are
partially similar to those imposed on them as children (e.g., excessive
caretaking of younger siblings, tending to the household). This parallel is
demonstrated by one parents statements, When I was 14-years-old, I had
to take care of all my siblings, clean the house every day, and cook so I
couldnt spend time with my friends. Within this scenario, these enforced
responsibilities on the teen are different enough from the parents own as
a child that they are communicated to the adolescent as easier and hence
fair. Thus, while the parenting behaviors in both the forcing autonomy
dialectical dilemma and the underprotecting corollary may present in a
similar fashion, the motivations underlying the parental behavior differ,
and therefore, should have different treatment targets.
OVERPROTECTING VERSUS UNDERPROTECTING TREATMENT TARGETS: MODIFYING
MALADAPTIVE PARENTAL COGNITIONS
The initial treatment target for both poles is to modify maladaptive
parental cognitions to facilitate more dialectical thinking patterns and
behaviors. For parents on the overprotecting pole, clinicians should target
their pervasive mistrust of other people, as well as their thoughts about
their adolescents being incapable of learning how to keep themselves safe.
Parents on the underprotecting pole differ from those in the overprotect-
ing pole in that they often view others, including their own children, as
having it easier than they did during their adolescence. Thus, it is
important to:
1) increase parental mindfulness and acceptance of the effects of their past
on their present parenting behaviors, 2) increase parents use of interper-
sonal effectiveness skills, and 3) increase use of middle path skills (e.g.,
validation, dialectical thinking and behavior).
Clinician Strategies for Parents
First, it is critical to help parents find their wise minds4 to assess what
is and what is not working in their interactions with their teen. Second,
highlighting the intergenerational parenting patterns, especially those that
4
Wise mind is a state of mind which represents the synthesis of the emotional and logical parts of
the brain. DBT encourages people to make important decisions using their wise mind.

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parents experienced as upsetting during their adolescent years, often


increases empathy for their adolescent in the present moment. Third, it is
important for clinicians to attend to indicators of parents histories of
abuse, trauma, and mental health problems. Clinicians can validate par-
ents past experiences using the biosocial theory, which acknowledges the
parents emotional vulnerabilities as well as their experiences of invalidat-
ing environments. Clinicians can reframe parents overprotecting behav-
iors as attempts to protect their adolescent from the kinds of adverse
experiences they experienced during their youth. The goal is for parents to
work towards an authoritative parenting style such that they reward their
adolescent for effective behaviors by a developmentally appropriate in-
crease in privileges (e.g., spending time with approved peers, joining the
school track team, etc.). At the same time, the clinician helps the parents
increase their mindfulness of urges to restrict their adolescents autonomy
when they experience triggers of their history of trauma; this exposure
often results in parents applying extreme punishments, engaging in exces-
sive rule setting, and restricting their teens independence.
For underprotecting parents, clinicians can reframe parents neglectful
or angry behaviors as signs of exhaustion and needing help. Moreover,
clinicians should assess parents maladaptive cognitions toward their teen
(e.g., Why are you so sad? When I was your age I had to raise all five of
my siblings and drop out of school. All Im asking you to do is watch your
brother after school. I wish I had it that easy when I was your age.)
Increasing parents mindfulness about the impact of their past abuse or
trauma on their current judgments and behaviors is key to changing these
cognitions. At the same time, clinicians need to assist parents in finding a
synthesis by honoring the truths in their, as well as in their daughters,
perspectives. The goal is for parents to learn both how to identify triggers
of their past abuse or trauma that affect current parenting practices and
how to apply skills to cope with their intense emotions.
While we suggest that clinicians assess and address the influences of
parental trauma in the context of the adolescents therapy, clinicians
should be careful to abstain from directly treating the parents. The parents
can and should be referred for their own individual therapy. The adoles-
cents individual clinician should collaborate with the parents health care
provider to facilitate active communication and progress toward treatment
goals. Unfortunately, many of these parents have difficulty following up
with referrals, and therefore clinicians can teach DBT distress tolerance
skills (e.g., self-soothe, distraction techniques) for parents on both poles to
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Table 2. DIALECTICAL COROLLARY: OVERPROTECTING VERSUS


UNDERPROTECTING

Clinician techniques for


Treatment Target Clinician techniques for parents adolescents

Target: Modify parental Observe cues of parental history Improve interpersonal


schema of others of trauma while assessing effectiveness skills
(i.e., people are never parents past experiences Intervene with environment
trustworthy) and Validate parents past Increase adolescents
modify parental experiences using biosocial healthy relationships with
schema of adolescent theory peers, teachers, romantic
(i.e., teen incapable Validate parents cognitions partners
of learning how to about feeling misunderstood Increase prosocial routines
keep herself safe) to and either a) reframe and activities outside the
be less rigid and overprotective parenting home
more flexible behaviors as the parents trying Teach self-care skills
Target: Modify parental to protect teens from the bad Improve emotional
schema of others things that happened to them regulation skills
(i.e., everyone else in their youth or; b) reframe
had it so easy) and of underprotective parenting
adolescent (i.e., teen behaviors as parents being
should be able to exhausted and needing help
handle adult Assess parental cognitions about
responsibilities) to be the environment (e.g., Do
less rigid and more parents think supervised after-
flexible school activities are safe
enough for adolescents? Do
parents believe they were dealt
an unfair hand in life and
their adolescent has it much
easier than they did?)
Increase mindfulness of impact
of past trauma on present
parenting behaviors
Refer parents to individual
therapy
Teach distress tolerance skills
Increase perspective taking skills
on teens current experiences
Elicit current goals for
relationship with teen
Increase validation of teens
Help parent change parenting
behaviors

use when certain triggers from their past trauma get activated (See Table
2 for a summary).
Clinician Strategies for Adolescents
For overprotected and underprotected adolescents, it is useful not only
to increase healthy relationships with peers, teachers, and romantic part-
ners but also prosocial routines and activities outside of the home. This
must be done slowly and with parental support since such activities may
accidentally trigger deeply rooted maladaptive parental responses associ-
ated with the adolescents development and agency. It is useful to teach the
adolescent to use her interpersonal effectiveness skills for communicating
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preferences to her parents, while explaining how achieving this positive


outcome may affect her mood or behavior or make the parents life easier
in some way. For example, If you allow me to join the school softball team
and practice afterschool, it would make me feel better about myself and
teach me to be more responsible. I would call you before and after practice
and keep my grades at a B average to remain on the team, which I know
is important for you and Dad.
It may be necessary for clinicians to intervene on behalf of the
adolescent more than is typically recommended for DBT clinicians, who
ordinarily rely on using consultation to patient strategies. Clinicians should
heavily utilize other resources that provide parents with additional support
(e.g., mental health treatment, case management and respite services,
financial aid, housing and/or legal resources). Additionally, the clinician
may assist the teenager in finding additional support and validation by
identifying existing parent-approved activities and places within her com-
munity (e.g., church or other religious institution, community recreational
center, extended family member or older adult siblings home).
ALTERNATIVE TREATMENT TARGETS FOR CLINICIANS UNABLE TO ACHIEVE
DIALECTICAL SYNTHESIS
We have encountered cases where clinicians were unable to achieve the
suggested treatment targets with parents and adolescents. While there is
no set time frame for when a clinician should give up or change course
from suggested treatment targets, in our experience, if a clinician is unable
to help parents develop suggested DBT skills during Stage One of
Treatment (i.e., 20 weeks), the consequence is often an increase in
depressive symptoms and hopelessness in the adolescent. After meeting
with the DBT consultation team, the clinician may consider becoming
more acceptance oriented and helping the teen radically accept (for now)
that her parents, despite everyones best efforts, are not yet able to validate
her vantage point or find a synthesis.
Clinician Strategies for Parents
First, clinicians need to radically accept that they were unable to shift
the parents away from an extreme pole. Second, clinicians should be
mindful of their judgments and feelings of frustration and they need to
keep validating the parents challenges in finding a synthesis via collateral
sessions. These sessions enable the clinician to maintain therapeutic rap-
port and to promote parents willingness to allow the adolescent to
continue in treatment. It is important for clinicians to initiate periodic
check-ins with parents to avoid communicating solely when the adolescent
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DBT for Suicidal Latina Adolescents

and family are in crisis (e.g., in response to an adolescents suicide


attempt).
Clinician Techniques for Adolescents
It is important not to induce hopelessness in the adolescent; rather, the
clinician can provide the adolescent with psychoeducation, explaining the
reasons that may have obstructed a parents ability to become more
dialectical at this time. The clinician works with the adolescent to help her
practice not only self-validation, but also how to validate her parents
vantage point from a biosocial perspective. This is a skill the adolescent is
taught in her weekly DBT skills group. It is also important to assist the
adolescent in identifying her thinking mistakes about the reasons that
she and her parents were not able to achieve a synthesis. For example,
rather focusing on than internal attributions, my mom wont allow me to
join the dance team because I cant be trusted, consider that my mom
wont allow me to join the dance team because shes afraid that something
bad will happen to me. Teaching adolescents distress tolerance skills and
emphasizing the independence that awaits many of them when they turn
18 can help counter the teens tendency to feel hopeless.
CONCLUSION
This paper described the dialectical corollaries we frequently observed
in treating Latina adolescents who were suicidal and their families. Old
school versus new school encapsulates extreme behaviors fueled by
norms of the parents country of origin clashing with the adolescents
adaptation of norms present in the current environment. Overprotect-
ing versus underprotecting represents extreme parenting behaviors that
stem from early parental exposure to trauma. The suggested treatment
targets focus on enhancing mindfulness skills, validation, dialectical
thinking, and correcting cognitive distortions. We have also outlined
suggestions to help clinicians manage therapeutic impasses (i.e., dia-
lectical failures).
It is important to note that the dialectical corollary of old school versus
new school may be present in other immigrant dyads. Additionally, the
dialectical corollary of overprotecting versus underprotecting may apply to
parents from other cultural backgrounds that experienced similar histories
of trauma. We hope that the aforementioned dialectical corollaries and
proposed treatment targets and techniques will enhance the standard
adolescent DBT protocol and improve outcomes among suicidal, Latina
teenagers and their families.
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Acknowledgement: The authors wish to thank Elizabeth Courtney-Seidler, PhD, for her help in
reviewing the manuscript.

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Mentalization and Dialectical Behavior
Therapy

CHARLES R. SWENSON, M.D.*


LOIS W. CHOI-KAIN, M.D., M.Ed.#
Dialectical Behavior Therapy (DBT) and Mentalization-Based Treatment
(MBT) are two approaches to the treatment of borderline personality disorder
(BPD). While DBT has the most empirical support, MBT has a small but
significant evidence base. Dialectical behavior therapy synthesizes behavior-
ism, mindfulness, and dialectics, while MBT is conceptually anchored in
psychoanalysis, attachment theory, cognitive neuroscience, and developmen-
tal psychopathology. While coming from strikingly different orientations,
DBT and MBT therapists share more interventions and stances than one
might suppose. The central purported active ingredient of MBT is the capacity
to mentalize, which is crucial for the formation of secure attachment, and this
ability is thought to be weak and unstable in individuals with borderline
personality disorder. This article explores the question of whether or not
mentalizing is already present in DBT practice, whether it would be com-
patible with DBT conceptually and practically, and whether a focus on
mentalizing would be of use to the DBT therapists and their patients.

KEYWORDS: Mentalization; mentalization-based therapy; MBT,


dialectical behavior therapy; DBT, borderline personality disorder

INTRODUCTION
Mentalization-based treatment (MBT) is a psychosocial treatment for
borderline personality disorder (BPD) that has gathered significant sup-
port both in controlled research trials (Bateman & Fonagy, 1999, 2001,
2003, 2008, 2009) and in increasingly widespread application (Bateman &
Fonagy, 2012). While MBT structures treatment around goals, agreements
between therapist and patient, and crisis planning protocols, the defining
feature and purported active ingredient in MBT is mentalization. Thera-

* University of Massachusetts Medical School, Department of Psychiatry, Worcester, MA;


#Harvard Medical School, Department of Psychiatry, McLean Hospital, Belmont, MA. Mailing
address: Charles R. Swenson, M.D., 110 Main Street, Northampton, MA 01060. e-mail:
c.robert.swenson@gmail.com
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

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pists adopt a curious, not-knowing stance, monitor attachment and men-


talizing capacity, and use interventions aimed to restore or maintain the
capacity of patients to mentalize. The MBT therapist shares a written case
formulation with the patient that highlights the way in which problems
with mentalizing were influenced by early attachments, have played a role
in relationship patterns, and are likely to manifest in psychotherapy.
Alongside the individual therapy, patients are provided psycho-education
and structured exercises to bolster comprehension about mentalizing.
Patients participate in group therapy during which they mentalize in order
to to generalize their capacity.
Allen, Fonagy, & Bateman (2008) have claimed:
. . . we believe that therapists of all persuasions can benefit from a solid
understanding of mentalizing and, furthermore, that patients also can
benefit from this understandingregardless of the type of treatment in
which they are engaged. (p. 20; italics from the original)
Given that MBT is supported in controlled research trials, that it was
originally designed for treating borderline personality disorder, and that
the focus of MBT is the strengthening of capacities in the patientall of
which are features of dialectical behavior therapy (Linehan, 1993)
mentalizing may be of interest to DBT therapists.
Both MBT and DBT share some proximal aims: establish a secure
attachment relationship in therapy, use empathy and validation in a
reciprocal relationship, strengthen patient capacities to reduce emotional
dysregulation and impulsive behaviors, and enhance self-awareness, atten-
tional control, and flexible thinking in the contexts of emotions and
relationships.
All of this is especially interesting given that MBT and DBT are derived
from such different foundations. Mentalization-based treatment comes
from psychoanalysis, attachment theory and research, and developmental
psychopathology. Dialectical behavior therapy synthesizes acceptance-
based approaches, behavioral science, and dialectical philosophy. Mental-
ization-based treatment has a more unitary focus than DBT, with MBT
centering on an instability in mentalizing as the underlying problem in
borderline personality. Dialectical behavior therapy does not posit an
underlying problem, but focuses on changing targeted behaviors with a
range of strategies to address a range of controlling variables (Linehan,
1993). In this review we will define mentalizing and specify some of its
essential facets, consider how the conceptual underpinnings of MBT might
influence the importation of mentalizing into DBT, scan the packages of
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DBT strategies to see if mentalizing already exists in DBT and whether it


would be compatible with DBT, and consider whether and how the DBT
therapist and patient may benefit from a mentalizing focus.
WHAT IS MENTALIZING?
Mentalizing is surprisingly difficult to grasp, perhaps because it is so
ordinary and ubiquitousthe capacity that makes us human (Allen,
Fonagy, & Bateman, 2008)yet named by an unfamiliar term. Further, a
behaviorist might at first recoil from the frequent use of the term mental
states since it sounds imprecise and as if it refers to hypothetical men-
talistic entities. In fact it simply refers to constellations of cognitions,
emotions, perceptions, and sensations that are activated in concert with
one another. For instance, desires and intentions are mental states.
As Allen, Fonagy, & Bateman (2008) state, we are mentalizing when
we are aware of mental states in ourselves or otherswhen we are thinking
about feelings, for example. (p. 3). The gist of mentalizing is holding
mind in mind (authors italics, p. 4). Further: More elaborately, we define
mentalizing as imaginatively perceiving or interpreting behaviors as con-
joined with intentional mental states. (p. 4). So whenever we are aware of
a behavior, of our own or of someone else, being part of a mental state,
part of the mind, we are mentalizing. Consider an example often used in
teaching mentalization. If I simply notice a physiological eventmy heart
is racingas a fact, without reference to any of my mental states, I am not
mentalizing. My awareness is simply the awareness of a fact, a piece of
reality, without a mental context. As soon as I notice my associated
anxiety or thoughts, I am beginning to mentalize. If I elaborate further on
the possible causes of my racing heart, and consider my options in
response, I am mentalizing further, with greater richness and flexibility.
The MBT therapist wants to promote mentalizing that is grounded in
reality, is understandable with reference to intentions, is rich in content,
and is sustained in the context of intense affects and attachment activation.
One author of this paper (CRS) met with a 35-year-old patient in
psychotherapy. She presented with the concern that her tendency to be
overly conciliatory to others was interfering with her hopes to attain a
higher-level management position in her company. One morning, on the
way into a session from the waiting room, while holding a cup of coffee,
she asked if she could bring coffee into the office. She was implicitly
mentalizing , guessing (inaccurately) that the therapist might object. While
the therapist thought the question sounded polite and respectful, he also
thought it was a bit surprising and unnecessary because he usually had
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coffee during sessions with her. In wondering why she had asked his
permission, he was mentalizing about her mental state. As the session
began, the therapist, from a not-knowing posture, indicated his sense of
surprise to the patient, and he invited her to consider why she felt the need
to ask about the coffee. He was making a gentle inquiry, inviting her to
mentalize explicitly about her intentions and concerns. Under the gentle
pressure of inquiry, the patient responded defensively, as if she were being
attacked by the therapist. She was briefly at risk of losing her capacity to
mentalize, but upon reassurance that no attack was intended, she began to
reflect on (mentalize) her own behavior regarding the coffee, and she
quickly connected it to her tendency at work to be overly polite and
conciliatory. In this kind of reciprocal mentalizing, the implicit is made
explicit, and the process as described, which included inquiry about the
self and the other, is typical when both parties sustain the capability to
mentalize in psychotherapy. It moves the process forward. It is when
mentalizing breaks down that the trouble begins, as we shall discuss.
It must be clear by now that mentalizing is commonplace. When we
wonder why we suddenly feel uncomfortable with no obvious cause, or
when we ask why someone says something that we dont understand, we
are mentalizing. When we know when to speak and when to listen in a
conversation, we are mentalizing. As we write the words for this article
right now, we are mentalizing by imagining what your state of mind will be
as you read them.
When are we not mentalizing? First, if we are trying to understand the
geologic origins of a large rock in the center of a field, we are not
mentalizing. Mentalizing is a profoundly social construct. Still, at times we
fail to mentalize in relationships, which is likely to set the stage for
interpersonal and emotional difficulties. Mentalization-based treatment
experts describe prementalistic states at times that mentalizing goes off
line (Table 1). If we (as the client) cling to the thought that someone hates
us, despite evidence to the contrary, we (wrongly) consider our thought to
be identical to reality, and we are operating in a mode of psychic
equivalence. The MBT therapist would work to move the patient to a
mentalizing mode. When we are simply talking, such as intellectualizing, in
a manner that is only loosely related to reality and not connected to
authentic emotional responses or appraisalsin other words, if full of
malarkey, the MBT therapist might consider the speaker to be in pre-
tend mode, and would work to move to a mentalizing mode. Lastly, if we
need to provide concrete demonstrations of how we feel or how others feel
about us in interpersonal communications, for example self-harm as a sign
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Table 1. PREMENTALIZING MODES UNDERPINNING SYMPTOMS OF BPD

Prementalizing Mode Description DBT Translation Example


Psychic Equivalence Equating what is in ones own Emotion mind rules without A patients boyfriend does not
mind with reality where any balancing influence of call back immediately, and
ones interpretation of an rational mind which might the client becomes
event is held with absolute evaluate other alternatives. absolutely certain that this is
certainty as the truth Assumptions made without because he is with another
Concrete understanding checking facts woman despite any evidence
to suggest this
Pretend Mode Complete disconnection Rational mind decoupled from A patient can regurgitate
between what is in ones emotional mind, elegant, complex statements
mind and what one communication of some sort about their psychology
embodies in their of script that does not based on cognitive learning
experience. Psychological represent a mindful in therapy, yet this has no
representation of experience awareness of what one tie to their authentic
Mentalization and Dialectical Behavior Therapy

is empty, canned, and experiences experience or to making


nonspontaneous Feeds into apparent relevant change in their life
Pseudomentalizing competence and relates to outside of therapy
inhibited grieving
Teleologic Mode Needing observable evidence Unrelenting crisis and active A patient cuts to prove how
to prove mental states in a passivity are ways that a much they are struggling or
way that bypasses a need to person demonstrates needs a therapist to go
mentalize or imagine what observably their pain so above an beyond, perhaps
one or someone else feels others do not need to crossing a boundary to
mentalize their mental states prove they care

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of suffering or having someone drop everything to take care of us, we are


operating in teleological stance. Here again, the MBT therapist would
aim to restore mentalizing.
The MBT therapist tries to sustain a mentalizing stance toward the
patient and himself. This involves several characteristics. The therapist is
curious and inquisitive, proceeding with a not-knowing attitude. In other
words, he is interested, assuming that certain behaviors arose from states
of mind, but without assuming what those states are in advance of inquiry.
He tries to remain experience near in his thinking and inquiry. He is not
looking for content, or to catalyze insight; he is more interested in
fostering a mentalizing process. He repeatedly invites the patient into a
collaboration, mentalizing along with him. The mentalizing therapist is
relatively transparent, using self -disclosure of his own thought process and
his feelings in the service of modeling his own mentalizing process. In
doing so, he heightens the authentic, reciprocal, conversational, flexible,
and spontaneous nature of the interaction.
There is such a thing as more and less skillful mentalizing. More skillful
mentalizing will include these three qualities: accuracy, richness, and
flexibility. Accurate mentalizing means that the individuals understanding
of mental states (of self or others) is relatively close to reality. Mentalizing
with richness means that the individuals understanding is well elaborated,
with considerable detail, perhaps invoking history and a meaningful,
coherent, biographical or autobiographical narrative. For mentalizing to
be flexible means that the individual is capable of considering various ways
to understand the behavior of interest.
CONCEPTUAL UNDERPINNINGS OF MBT AND IMPLICATIONS
FOR MENTALIZING IN DBT
Mentalization-based treatment and the concept of mentalizing grew out
of three main foundations: psychoanalysis, attachment theory and re-
search, and developmental psychopathology. Coming from conceptual
foundations so different from those underlying DBT, it is worthwhile to
consider whether mentalizing brings with it assumptions and positions that
are alien to DBT, even if the practice seems to be transportable into a DBT
treatment.
Mentalization-based treatment is most clearly derived from psychoanal-
ysis, and involves a persistent investigation of conscious and unconscious
states of mind underlying a given behavior. The therapist assumes an
internal road map of mental representations and narratives, and seeks to
make the implicit explicit, whether in himself or in his patient. Psychoan-
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alytic approaches to the understanding of borderline pathology congealed


in the 1970s around two models, Kernbergs (1976) ego psychology and
developmental object relations theory, and Kohuts (1977) pathology of
the self, with a focus on the pathology resulting from failures of empathy
in early development. While MBT is not a simple descendant of these two
models, incorporating attachment theory and cognitive neuroscience as it
does, it does seem to derive elements from both. It shares Kernbergs
elaboration of mental representations of the concepts of self and other,
while also sharing Kohuts focus on empathy, attachment security, and
their re-enactments in the psychotherapeutic relationship.
Mentalization-based treatment differentiates itself from standard con-
ceptualizations and practices of psychoanalysis such that it is the psycho-
analytically derived model most accessible to the DBT therapist. While the
MBT therapist pursues and prompts inquiries into the inferred inner
world of mental representations and narratives, insight into past, present,
and the transference is not the goal. His quest is to increase the patients
capacity to mentalize, and to maintain mentalization in the context of
intensified affective states and hyperactivated attachment. He is of the
belief that more stable mentalizing will result in greater attachment
security, more flexibility, and greater freedom to explore life and pursue
goals. While the capacity to mentalize is more complex, more multifaceted
than any particular DBT skill, the relentless focus on acquisition and
generalization of a capacity is familiar in DBT. The not-knowing attitude
of the MBT therapist as he approaches the patient (and himself) is
consistent with DBTs behavioral stance insisting on assessing rather than
assuming.
The psychoanalytic patient is given instructions to free associate, not so
in MBT. The patient in psychoanalysis is encouraged to elaborate on
fantasies about the analyst, not so in MBT. Psychoanalysts tend to establish
a therapeutic position of relative objectivity and technical neutrality; the
MBT therapist is more active, more transparent, more self-disclosing, more
explicitly empathic, and more playful than the psychoanalyst, more akin to
a stance in DBT. When the MBT therapist works to mentalize the
transference, he is referring to efforts to encourage the patient to elabo-
rate on perceptions, thoughts, and feelings about the therapist, not to the
more typical psychoanalytic work of illuminating and interpreting the
transference as a projection of past relationships onto the therapist. All of
which leaves a more here-and-now experience-near process-over-content
stance that bears some resemblance to the stance in DBT. Just as one can
usefully add Buddhist mindfulness practices into ones secular life without
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importing any more elaborate Buddhist belief system (Thich Nhat Hanh,
1996), a DBT therapist could consider adding aspects of mentalizing into
his practice without importing behaviorally dystonic psychoanalytic belief
systems.
The psychoanalytically oriented inquiry of the MBT therapist into a
behavior of interest takes a different shape than the behaviorally oriented
inquiry of the DBT therapist. The MBT therapist contextualizes the
behavior in a coherent narrative of the kind that is found to accompany
secure attachment relationships, and encourages continuity of reflection to
do so. The DBT therapist, while interested in narratives as a way of
grasping and validating the patients experience and behaviors, breaks the
narrative into bits, discrete behaviors that can be assessed as functional or
dysfunctional, then modified or replaced by treatment. While the search-
for-the-coherent narrative and the breaking-the-narrative-into-bits theories
represent two directions that can be pursued in the same treatment, MBT
therapists lean toward the former and DBT therapists lean toward the
latter.
Attachment theory and research, beginning with Bowlby (1982) and
elaborated by others (Ainsworth, Blehar, Waters, &Wall, 1978; Main,
1995; Meins, Fernyhough, Russell, & Clark-Carter, 1998; Meins, Ferny-
hough, Fradley, & Tucker, 2001; Fonagy, Gergeley, Turist, &Target,
2002), is the second foundation of MBT. Space prohibits any meaningful
review of this area and its relevance to MBT, but the outlines of the
argument are as follows. Securely attached caretakers tend to accurately
and flexibly imagine and interpret the mental states of the child, respond-
ing in a way that helps the child understand and manage his own distress.
This is how secure attachment facilitates the development of mentalization
(Fonagy, et al., 2002), and the process of mentalization facilitates secure
attachment. A distressed child sends a nonverbal signal, such as crying,
and the caretaker must interpret the childs mental state and respond in a
way that is both contingent (i.e. resonant) as well as marked, or differen-
tiated as a metabolized and re-presented version of what the caretaker
imagines as the childs experience. If the caretaker is able to provide this
type of marked and contingent mirroring when the child is emotionally
distressed, the child then begins to develop a coherent sense of his own
experience via the development not only of an appreciation for how his
caretaker sees him but also how he experiences himself.
The lessons of attachment research are at the core of the formulations
and concerns of the MBT therapist. The MBT therapist attempts to
enhance both attachment and mentalization by providing marked and
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contingent mirroring, which simultaneously provides validation and alter-


native perspectives on the patients experiences. Like the DBT therapist,
the MBT therapist balances an attitude of validating the patients point of
view and experience, while also promoting the appreciation of other points
of view to promote change.
The DBT therapist assumes that an important attachment relation-
ship is central to DBTs effectiveness. He bases his theory of causation
of borderline behavior patterns on the hypothesis that the patients
emotional dys-regulation emerged in the context of an invalidating
environment, which overlaps considerably with the MBT formulation
of the caretaking environment with deficiencies in responsiveness,
attunement, and marked and contingent mirroring. And he places a
high priority on noticing disruptions or rifts in the therapy relationship,
on validating the patients experiences, and on repairing the relation-
ship again and again. While DBT does not incorporate language
associated with attachment theory as MBT does, the concepts are
present. When Linehan (1999) found that individuals presenting with
both borderline personality disorder and substance use disorders were
less likely to form an attachment with their DBT therapists than those
presenting with borderline personality disorder without substance
abuse, she overtly added in several attachment strategies to augment
the strength of the bond (Linehan, et. al., 1999). Even though the
concepts and importance of attachment are already built into DBTs
theory and practice, still it may be of value for DBT therapists to study
the emerging findings in this very active area of research.
The third conceptual pillar for MBT is developmental psychopathol-
ogy. The capacity to mentalize would be an expected outcome in a
good-enough environment, and failures to mentalize are thought to cor-
relate with nearly all forms of psychopathology. It seems that autism is a
most severe example of psychopathology in which the capacity to mental-
ize is stably limited, presumably due to a genetic basis. The patient with
severe antisocial pathology shows a limitation in mentalizing capacity and
the individual shows little or no appreciation of the impact on others. As
mentioned, the pathology of borderline personality disorder is explained
by a variable weakness in the capacity to mentalize, worsened in states of
emotional arousal and activated attachment. Further, attachment research-
ers would categorize most individuals with borderline personality disorder
as having a form of insecure attachment known as disorganized attach-
ment. (Main & Solomon, 1986).
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MENTALIZING IN RELATIONSHIP TO DBTS CORE STRATEGIES


We now line up the complex practice of mentalizing alongside three
overarching groups of strategies in DBT: change-oriented, dialectical, and
acceptance-oriented. Dialectical behavior therapys change-oriented pack-
age centers on problem-solving strategies, which begins with behavioral
assessment using the procedure of behavioral-chain analysis. From an
MBT perspective, the conduct of behavioral-chain analysis can easily be
understood as a structured form of mentalizing. The therapist proceeds by
holding all preexisting assumptions about the patient at bay while engag-
ing in a structured inquiry about the steps in the chain leading up to and
following the problem behavior. The open-minded, not-assuming attitude
overlaps with the mentalizing stance. The collaborative search for relevant
sensations, perceptions, emotions, and cognitions, framed by the template
of the chronological behavioral chain, parallels the collaborative process
used by the MBT therapist and patient to mentalize the patients behavior
and experience by elaborating on states of mind. The DBT therapist
considers a wide range of possible explanations as the behavioral chain
analysis proceeds, consistent with the flexibility of the most skillful men-
talizing, and brainstorms with the patient about possible solutions.
It is a hallmark of skillful mentalizing that states of mind are under-
stood to be representations of reality but are distinct from reality. Simi-
larly, for the DBT therapist the behavioral chain, co-constructed by
therapist and patient, is considered a template, a work in progress, a useful
tool for illuminating controlling variables. The story embedded in the
chain is a story, it is not reality itself, and it changes as more data is
added. In conclusion, it seems that behavioral chain analysis in DBT is a
structured form of mentalizing from the perspective of the MBT therapist,
akin to Allen, Fonagy, & Batemans (2008) contention that cognitive
modification in mindfulness-based cognitive therapy (Segal, Williams, and
Teasdale, 2002) can be seen as a structured form of mentalizing.
MBT therapists also employ chain analysis to understand self-harm.
Unlike in DBT, the purpose is not to find and provide behavioral solutions
to the patient. Instead, the MBT therapist helps the patient to think about
the interpersonal context of the intense affects that led to a collapse of
mentalizing. Self-harm is seen as a byproduct of pre-mentalistic states
(Table 1). In order to remedy this vulnerability to self-harm, the MBT
therapist aims to sustain reflective functioning in interpersonal situations
so that the patient can identify, assess, and then organize solutions to
problems. In both models, the therapist helps the patient to have an
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organized way to assess a chain of events, to illuminate the story, and to


consider solutions. But the DBT therapist is more likely to prompt and
reinforce the practice of skillful behaviors as the solution, while the MBT
therapist remains focused on reflective functioning and sustained mental-
izing, assuming that this will lead the patient to be a more effective
problem solver in her own right.
Therapists using MBT try to establish conditions that are most condu-
cive to mentalizing, to finding balance between several dichotomies, to
keeping the attachment to the therapist that is neither too hot (hyper-
activated) nor too cold (detached), encouraging the mentalization of self
and of other; and ensuring the mentalization of both cognitive and
affective processes. MBT therapists are trying to find the middle path
(without using the DBT term) and also finding the right balance of
certainty and doubt. Dialectics is pervasive in DBT, finding middle paths
between extremes, and promoting balance in the context of dys-regulation.
The dialectician in DBT can feel at home within the MBT therapists
interest in balance across several dimensions and in the high regard for
improvisation, creativity, flexibility, and spontaneity.
So we find that in spite of obvious differences MBT and DBT share a
number of features in the realms of what the DBT therapist considers the
change agenda and the dialectical philosophy. Nowhere is this more true
than when we consider how the mentalizing stance and interventions line
up alongside DBTs acceptance-oriented package, which includes mind-
fulness practices, validation strategies, reciprocal communication strate-
gies, and two of the four sets of skills (core mindfulness skills and distress
tolerance skills). As Allen (2013) discussed in detail, mentalizing as a
concept and practice is closely related to and dependent upon mindfulness
as a concept and practice (pp. 113-133). Mindfulness consists of bare
attention to what enters our awareness, attention to simply what is, without
judging, elaborating, or thinking further about it. When we are mindful of
the breath, we are aware of selected aspects of the breath; as attention
strays from the breath, we notice the straying and simply come back to the
breath. Kabat-Zinn (1994) defined mindfulness as paying attention in a
particular way: on purpose, in the present moment, and non-judgmentally
(p. 4) to the unfolding of experience moment by moment. Therapists in
DBT engage in mindfulness practice themselves, and bring mindful atten-
tiveness into therapy sessions as a way to enhance awareness, to see reality
as it is, and to self-regulate. One of the four sets of skills taught in DBT is
core mindfulness, core because this kind of attentive awareness in the
present moment, without judgment, is a foundation and a preliminary step
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for the practice of other skills. Dialectical behavior therapy team meetings
begin with a mindfulness practice, and teams use mindfulness to self-
regulate.
Similarly, as Allen explained (Allen, 2013), mindful awareness of states
of mind, sometimes described in MBT as holding mind in mind, is the
first step of mentalizing. Self-awareness is core to both DBT and mental-
izing in so far as it includes awareness of thoughts, feelings, perceptions,
sensations, even consciousness. Central to both MBT and DBT is the
position, which is also inherent in the practice of mindfulness, that what is
going on in the mind is separate from reality, and that the practice of
mindfulness strengthens this understanding. Prementalistic states in
MBT embody difficulties in adequately coupling and decoupling reality
from experience (Table 1). Once awareness illuminates the workings of the
mind and the perception of reality, both MBT and DBT therapists follow
the mindful path of acceptance, whether positive or negative: what is, is.
Dialectical behavior therapys distress tolerance skills module is centered
on the attempt to see reality clearly, to willingly accept it, and to learn
techniques to tolerate the painful consequences of some aspects of reality.
While there is significant overlap between mindfulness and mentaliza-
tion, the two concepts part ways. While the mindfulness practitioner
simply notes an observed phenomenon in mental experience (e.g., a
thought), and lets it come and go and transform, the mentalizing therapist
elaborates further on the phenomenon, spelling out a coherent narrative of
history and context in which it makes sense. For the MBT therapist,
mindfulness is a foundation and a first step in mentalizing. For the DBT
therapist, in practicing therapy and in teaching mindfulness skills to the
patient, the emphasis is on simply noticing, or simply describing. This is
used to see more clearly, to perceive reality more accurately, to strengthen
attention, and to regulate the mind. As we shall see, the MBT process of
elaborating on awareness can be found more clearly in the DBT therapists
use of levels of validation.
Linehans teaching about validation in DBT has evolved over time.
While at first she portrayed validation as the sugar coating that helps the
patient to tolerate the bitter pill of CBT-based problem-solving strate-
gies, validation has come to be seen as having a potent healing impact in
its own right. It strengthens problem-solving, counters self-invalidation,
teaches self-validation, strengthens the therapeutic relationship, and can
directly help to regulate intense emotions (Linehan, 1993). Mentalizing
overlapping concepts of empathy, mindreading, mindfulness, metacogni-
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tion, and theory of mind (Allen, Fonagy, & Bateman, 2008)also overlaps
DBTs levels of validation, of which there are six.
The first level of validation entails careful listening in a wide awake
posture, essentially mindful listening, which is also the first step in the
practice of mentalizing. The DBT therapist assumes that whatever is being
validated makes sense, somehow. The MBT therapist assumes that what-
ever is being mentalized will be found to be part of a coherent narrative.
The stance in level one of validation is essentially as described in the
mentalizing stance, including curiosity, inquisitiveness, and not-know-
ing. In DBTs level two of validation, the therapist reflects back to the
patient what he has received. This includes using the patients own words
to verbally reflect or mirror, and using facial expression and body
postures to resonate with the patients communication. Clearly, mentaliz-
ing relies heavily on the process of reflecting, much as is prescribed within
DBTs second level of validation. In addition, as was discussed above, the
MBT therapist looks to use marked and contingent mirroring in the
reflecting process, applying lessons learned in careful attachment research
examining sequences between caretakers and young children. The DBT
therapists reflecting process in level two might be enriched by studying
this important developmental discovery.
In DBTs third level of validation, the therapist articulates the unar-
ticulated to the patient, adding something to what the patient communi-
cated, a process of mindreading, reading between the lines of what the
patient has said, while waiting to see if the patient confirms the accuracy
or inaccuracy of the therapists comments. This might, in the context of
mentalization, be the beginning of inquiry, of trial and error, of feeling his
way in to the patients states of mind underlying the original communi-
cation. These first three levels of validation in DBT facilitate tuning in to
the patient, doing trial and error mindreading, and getting in synch with
the patient, all of which overlap considerably with the attentive awareness
of the mentalizing therapist, setting the stage for accurate, rich, and
flexible mentalizing resulting in further elaboration.
In the fourth and fifth levels of validation, the DBT therapist tries to
make more specific sense of the way in which the behavior in question is
valid, either by looking to historical background (Level 4), biological
factors (Level 4), or current context (Level 5). It is in the practice of these
two levels of validation that one finds the closest parallel in DBT to
mentalizing in its fullest sense, elaborating the patients behavior in the
context of thoughts, emotions, perceptions, actions, and environmental
events. You might say, looking at DBT through the prism of an MBT
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therapist, that in the practice of mindfulness and the first three levels of
validation, the DBT therapist is engaging alert attention, mirroring, or
attunement much as the MBT therapist does initially, and that in the
practice of levels four and five the therapist is inquiring and elaborating,
finding the narrative in which the behavior resides.
Still, the manner in which the MBT therapist mentalizes, especially in
the style and extent of elaborating, is not likely to be identical to the way
the DBT therapist uses validation in levels four and five. First, the MBT
therapist is betting the store on mentalizing and is probably seeking to
find a richer and more extensive biographical narrative than the DBT
therapist, who is looking to validation to balance the demanding and
time-consuming work of behavior change through problem solving. Sec-
ond, given that the DBT therapists highest priority is to find the validity
of the patients behavior in the current context (i.e., Level 5), in the service
of teaching the patient to self-validate, there may be a relative skewing of
validation away from rich and coherent narratives about the past which
would fit within MBT. It is even possible that the DBT therapists
emphasis on finding the validity of the patients behavior in the current
contextnormalizing the patients behavior could be anti-mentalizing in
that it collapses the focus on having the patient spontaneously evaluate her
own experience.
The sixth level of validation refers more to a stance than any one type
of intervention, and it too overlaps with some recommendations for MBT
therapists. This level entails the stance of radical genuineness, and refers
to the radical level of honesty, transparency, and presence that the
therapist holds throughout the interaction with the patient. The therapist,
while maintaining the therapeutic role, acts toward the patient in a genuine
way, being himself much as he would with colleagues, friends, and
family members. He is not artificial, and it is validating to the patient in her
whole self, indicating that the patient is worthy of receiving this kind of
realness from the therapist. There is, implicit within radical genuineness,
a kind of reciprocity between patient and therapist, a transparency.
Mentalization-based treatment therapists too are looking for a high level of
openness, transparency, honesty about their own states of mind, and
reciprocity. In MBT sessions the therapist can be rather conversational,
not adopting an artificial therapeutic stance. Mentalizing is thought to
beget mentalizing, and in my experience, consistent radical genuineness
begets radical genuineness. One subtle distinction between DBT and MBT
on the technique of genuineness is that in DBT this type of self-disclosure
functions to validate the patient, supporting her in moving toward behav-
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ioral change, whereas in MBT this level of genuineness is offered as a way


to introduce alternative perspectives to the patient, which then may
facilitate finding solutions.
Just as the DBT therapist moves back and forth between validation and
problem solving, he also moves back and forth between two styles of
communication, the reciprocal and the irreverent styles. Mentalization-
based treatments mentalizing stance resonates with DBTs reciprocal
communication style. Reciprocal communication involves: responsiveness,
warmth, genuineness, and the judicious use of self-disclosure by the
therapist. Responsiveness is reminiscent of sensitive responding in the early
attachment studies, or attunement. It refers to the way in which the
therapist allows himself to have a genuine response to the manifest content
of the patients communications, letting himself be affected, moved, or
otherwise responsive. The patient will feel that the therapist has heard her,
has taken it in genuinely, and is affected. Warmth is another element.
Keeping the temperature of the therapy relationship somewhere be-
tween too hot and too cold, the therapist strives for warm responsiveness
that will be most conducive for change-oriented work in DBT and for
mentalizing in MBT. Beyond the warm, genuine, and responsive tone
maintained as much as indicated throughout the treatment, the therapist
uses forms of self-disclosure that are harnessed to strategic approaches and
circumscribed within the personal limits of the therapist and the patient.
By using self-disclosure, the therapist may be using it in the service of
reinforcement, cognitive restructuring, skills training, validation, or to
solidify the therapy relationship, among other options. Personal self-
disclosure involves the sharing of personal or professional information,
part of the transparency of the DBT therapist, which contributes to a
collaborative, were-in-it-together, attitude. Self-involving self-disclosures
include the therapist sharing reactions in the momentwarmth, irritation,
frustration, joy, etc.with the patient as harnessed for strategic purposes.
The overlap with the mentalizing stance is obvious. The MBT therapist
is to be present, nonjudgmental, open minded, transparent, flexible, warm,
and collaborative. In the view of the authors, the way in which the two
treatments differ in the application of these similar stances is more a matter
of degree than nature. Again, DBTs reciprocal style, which accompanies
the communication of acceptance, alternates with an irreverent style,
which is the DBT change-oriented style. While the MBT therapist centers
on the cultivation of a mentalizing stance throughout treatment by using
gentle challenges to the patient (who is persistently in pretend mode rather
than mentalizing mode), the DBT therapist centers treatment on a target-
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and change-oriented agenda, and will move between accepting and chal-
lenging, reciprocating and being irreverent, yet always promoting the
change agenda.
IN CONCLUSION
Our first conclusion is that if one understands what is meant by
mentalizing, one finds it in many locations in DBT: in the process of
assessment, in the practice of problem solving, in the pervasive influence of
dialectics, and most of all in the various strategies within the acceptance
package in DBT. There are striking overlaps with mentalizing in the
practices of mindfulness, validation, and reciprocal communication, and
affinities between mentalizing and important aspects of behavioral-chain
analysis.
Both MBT and DBT carry with them theories of change aiming to
strengthen resilience in the face of emotions and relationships. In DBT the
therapist, having established a secure and important attachment relation-
ship, stays focused on behavioral targets, and brings problem-solving tools,
including skills, to help the patient be able to change. During workshops,
Linehan has at times described DBT as requiring two overriding activities
by the therapist: on the one hand to be able to get into hell with the
patient and understand it from the patients perspective, and on the other
hand to have ways to get the patient out of hell, which in DBT involves
the problem-solving strategies and skills.
While the MBT therapist shares the goal of getting the patient out of
hell, there is a different conceptualization of how to do it. The therapist
uses empathic attunement and marked and contingent mirroring to in-
crease the patients self-awareness and attachment security. In that context
the therapist enables various dynamic perspectives on self and other to
evolve, providing the foundation for increased attentional, emotional, and
behavioral self-regulation. The patient brings more flexible and accurate
mentalizing to bear in response to what would be called triggers or
prompting events in DBT, ultimately improving self-regulation capaci-
ties and greater freedom in exploring the world and moving toward goals.
It is one of the strengths of DBT to offer such a rich problem-solving
repertoire and skills package. This requires micro-slicing a narrative into
behavioral bits that can be evaluated and modified. To do this while
maintaining and enhancing an attachment relationship (also much needed
in DBT) is difficult. The therapist augments the behavioral change em-
phasis with mindfulness, validation, and the improvisation, speed, move-
ment, and flow of dialectics. A familiarity with the role of mentalizing in
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fostering secure attachments, and an attempt to strengthen the patients


mentalizing capacities through greater elaboration of the patients narra-
tives during behavioral chain analysis, may strengthen the therapeutic
arsenal of the DBT therapist. The mentalizing focus may serve both to
strengthen the attachment to the therapist and to decrease problematic
emotions and actions generated in pre-mentalistic states.
Given the degree of natural overlap between DBT and MBT, the DBT
therapist can incorporate mentalizing in working with patients, counter-
balancing the effects of breaking down behavioral patterns into treatable
links with the benefits of strengthening metacognition, self-coherence,, and
attachment functioning. In the early stages of treatment in DBT, where a
therapist and patient are working together to move from behavioral
dyscontrol to behavioral control, the patient will typically be unable to
maintain a flexible mindset and wise minded balance when exposed to
emotionally evocative cues. At this moment in treatment the DBT thera-
pist, while assessing for DBTs typical skills deficits, might also detect the
features of prementalistic states, alerting him to the likelihood that men-
talizing has gone offline. The therapist might then use standard MBT
techniques to reinstate mentalizing through a curious, not-knowing stance
(much like beginners mind in DBT), combined with efforts to manage the
attachment in an attuned but modulated way, so that the patient can do
the work of DBT (or any therapy approach). While this effort to bring the
mind online when mentalization has been deactivated overlaps consider-
ably with inquiry and acceptance strategies in DBT, the rich descriptions
and examples of doing so in MBT can augment DBTs behaviorally
oriented method.
Throughout the course of treatment with patients who have BPD,
interpersonal problems within the therapy relationship are to be expected.
Mentalization-based treatment brings a flexible and nuanced set of tech-
niques that are flexible and empathic to address misunderstandings or
relational problems between the therapist and patient. The DBT package
of interpersonal effectiveness skills provides a guide to enhancing a
relationship through being gentle, acting interested, validating, and main-
taining an easy manner. Based as it is in attachment theory and psycho-
analysis, MBT provides a broad technique that engages and stabilizes the
patients ability to understand how he reacts to others and how others
experience him in the relationship.
Mentalization-based treatment techniques can complement DBT tech-
niques to stabilize identity problems inherent in BPD. Dialectical behavior
therapy helps the patient with BPD by supporting efforts to build a life
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that enhances self-respect, while decreasing behavioral tendencies that


destroy self-respect. Dialectical behavior therapy also addresses identity
issues through the core skills of mindfulness, which increases self-aware-
ness. The DBT therapist can incorporate MBT into treatment to allow the
patient to integrate the observations he makes of his experiences by
stabilizing the reflective capacity to be more coherent to oneself and others
in that self-awareness. Mentalizing allows the patient and therapist to
incorporate meaning and individuality into their lives to facilitate a unique
and vibrant sense of self.
In summary it occurs to us that the DBT therapists study of mental-
izing may bring some attachment-based perspectives and techniques that
will strengthen the attachment relationship. Just as hockey players can
benefit from some training in figure skating, DBT therapists might find
mentalizing to provide some new and effective moves in an attachment-
oriented direction.

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Towards the Development of an Effective
Working Alliance: The Application of DBT
Validation and Stylistic Strategies in the
Adaptation of a Manualized Complex
Trauma Group Treatment Program for
Adolescents in Long-Term Detention

SAMUEL J. FASULO, Ph.D.*


JOANNA M. BALL, Ph.D.*
GREGORY J. JURKOVIC, Ph.D.*
ALEC L. MILLER, Psy.D.#
The current paper details a case of adapting a manualized group therapy
treatment for youths experiencing chronic stress. It was used for use with a highly
traumatized and behaviorally disordered group of adolescents (ages 14 to 17
years) in long-term juvenile detention. The authors argue for a phasic approach
to treatment for this population, with the goal of the essential, initial phase being
the development of an authentic therapeutic alliance before other treatment goals
are pursued. The authors provide clinical examples of liberally and patiently
utilizing dialectical behavior therapy-framed acceptance-based strategies to
achieve this therapeutic alliance, and only then naturally weaving in more
traditional cognitive behavioral, change-oriented psychoeducational approaches
successfully.Clinical and research implications for effective treatment of trauma-
tized, detained youths are also discussed.

KEYWORDS: Complex PTSD; incarceration; dialectical behavior therapy;


adolescent therapeutic alliance

*Georgia State University, Atlanta, GA; #Montefiore Medical Center/Albert Einstein College of
Medicine, Bronx, NY. Mailing address: Samuel J. Fasulo, NYU Child Study Center, 1 Park Avenue,
7th Floor, NY, NY 10016. e-mail: samuel.fasulo@nyumc.org.
Author Note: Samuel J. Fasulo is now at the NYU Child Study Center, Department of Child &
Adolescent Psychiatry, NYU Langone Medical Center. Joanna M. Ball is now in private practice in
Hastings-on-Hudson, NY. Gregory J. Jurkovic is now Associate Professor Emeritus, Department of
Psychology, Georgia State University, Atlanta, GA and Consulting Psychologist, Georgia Department
of Juvenile Justice, Decatur, GA.
AMERICAN JOURNAL OF PSYCHOTHERAPY, Vol. 69, No. 2, 2015

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INTRODUCTION
Although adolescent criminal behavior is multi-determined, one con-
sistent finding is that 75% to 93% of youths entering the juvenile justice
system annually are estimated to have experienced some degree of
trauma (Adams, 2010). This is compared to 61.8% in a national sample
of adolescents who were exposed to a potentially traumatic experience
(McLaughlin et al., 2013). However, while only 4% of the general popu-
lation develops post-traumatic stress disorder by age 18 years (PTSD),
26% to 45% of the incarcerated juvenile population fulfills DSM-IV
criteria for this diagnosis (Merikangas et. al, 2010; Kerig et. al, 2009).
These statistics suggest that youths in the juvenile justice system have not
only been exposed to potentially traumatic events at a higher rate than
their nondelinquent peers, but also are experiencing relatively more PTSD
symptomatology. These statistics are supported by other researchers as
well (e.g., Kerig, 2012).
Moreover, the trauma histories of juvenile offenders are often complex
or developmental in nature, involving exposure to pervasive, longstanding,
and ongoing trauma and extreme stress with attendant problems (e.g., behav-
ioral and emotional dysregulation, cognitive distortions) that may not include
core PTSD symptomatology, such as intrusive memories, thoughts, and
feelings (Ford et al., 2012; Herman, 1992; van der Kolk, 2005, 2014). For these
youths the often traumatic and stressful experience of detention can be even
more damaging, and may increase their propensity for delinquent behavior
after detention (Becker & Rickel, 1998; Kupers, 1996).
In light of the marked role of traumatic, extreme stress in the behav-
ioral problems of serious juvenile offenders, it is clear that they need
evidence-based, trauma-informed treatment programming (National Child
Traumatic Stress Network, 2003). Although treatment in juvenile justice
settings can be daunting, especially when resources for evidence-based
mental health services are scarce, previous studies have shown that treat-
ment for juvenile offenders can be beneficial. For example, mental health
interventions reduce recidivism while punishment typically does not; in
fact, punishment-based programs have been positively correlated with
recidivism (Andrews & Bonta, 2010).
IDENTIFYING AN INTERVENTION FOR MULTI-PROBLEM,
INCARCERATED YOUTH WITH COMPLEX PTSD
The co-therapists (the first two authors) were assigned to identify an
evidence-based treatment to apply to a group of adolescent males with
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substantial, chronic trauma exposure histories in a detention facility


located in a southeastern city of the United States. At the time, evidence-
based treatments for this population were in the beginning stages of
development. One such program that appeared promising was entitled
Enhancing Resiliency: School-Based Group Treatment for Adolescents
Living with Interpersonal Trauma (Kaplan et al., 2003). This treatment
was particularly appealing for our setting because it was a unique and
integrative, manualized group treatment approach. In fact, it was the only
treatment available at the time specifically designed for adolescents living
with interpersonal trauma, experiencing ongoing significant distress, and
at risk for (or already experiencing) negative psychosocial outcomes
consistent with the clinical concept of complex or developmental trauma
referred to earlier. The manual by Kaplan et al. was developed by blending
large elements of three established, evidence-based treatments: Dialectical
Behavior Therapy (DBT; Linehan, 1993a, 1993b; Linehan, Armstrong,
Suarez, Allmon & Heard, 1991; Linehan et al., 2006; Miller, Rathus &
Linehan, 2007), Trauma Adaptive Recovery Group Education and Ther-
apy (TARGET, Ford et. al, 2003), and UCLAs Trauma/Grief Group
Psychotherapy Program (Saltzman et. al 2006). Since our use of the initial
version of the manual in the spring of 2005, the treatment has evolved
further and has been renamed Structured Psychotherapy for Adolescents
Responding to Chronic Stress (SPARCS; DeRosa, Habib, Pelcovitz,
Rathus, Sonnenklar, Ford, et al., 2006; DeRosa and Pelcovitz, 2009).
Because of this, as well as the fact that the goal of this paper is primarily
to highlight relational strategies rather than the delivery of cognitive
behavioral principles, we will refer to the treatment manual as the
Manual for the remainder of the paper.
Before utilizing the Manual in our setting, we contacted the manual
developers directly and asked for their permission to use and potentially
adapt the manual for use with a population for which it was not directly
intended; they gave us their permission and expressed an interest in
learning how it worked with a youth population in detention (DeRosa, R.,
personal communication, December, 2004). Based on clinical experience
working with complex trauma-exposed and behaviorally high-risk youths
and adults in a variety of outpatient, restricted and forensic settings,
multiple adaptations were made to the manual during treatment. Some of
these changes proved to be particularly relevant to work with behaviorally
disordered youths with complex PTSD histories.
In the remainder of this paper, we provide a clinical case example of
how a manualized treatment for youths exposed to chronic stress was
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adapted to meet the needs of a group of detained male adolescents with a


documented history of high levels of trauma exposure and related prob-
lems. More specifically, we highlight how acceptance-oriented and stylis-
tically irreverent interventions consistent with dialectical behavior therapy
principles were used to engage these youths authentically. Finally, we show
that this initial, relationally-focused engagement process set the stage for
the group members to self-initiate a therapeutic return to the exploration
of the skills-based portions of the Manual as originally designed. Thera-
peutically poignant moments are interwoven as appropriate not only to
punctuate the most salient clinical points we hope to make, but to also
bring to life the underlying tone and spirit of the therapeutic process
that the authors believe is essential for such authentic engagement to occur
in such a population of youths.
A CASE EXAMPLE: AN ADAPTATION OF SPARCS IN A
FORENSIC SETTING
PARTICIPANTS
The group was held at a juvenile detention center in a southeastern city
of the United States. This particular facility served as a short-term holding
facility for male and female youth arrested and detained for committing a
crime and awaiting adjudication. However, at the particular time that this
intervention was implemented, one of the long-term male detention facil-
ities in another area of the state had been temporarily closed. Adolescents
from that facility were therefore placed temporarily at various other
detention facilities throughout the state without having been given much
notice about the move. A trauma-based group was requested at this
particular short-term detention facility for a subset of the transferred male
adolescents. Many of them had been in a mental health unit at their facility
of origin, had significant trauma histories, and were struggling with
extreme emotional and behavioral dysregulation in response to the sudden
change.
INCLUSION/EXCLUSION CRITERIA
Adolescents were assessed for group appropriateness by unit casework-
ers utilizing the Youth Trauma Screening Inventory (YTSI) (Jurkovic,
Zucker, Ball, and Fasulo, 2003). This clinical instrument is designed to
review the history of traumatic and stressful life experiences and the impact
on juvenile delinquent and similar populations at high risk for complex PTSD
(see Ball et al., 2007, for a description of the measure). The only exclusion
criterion for the group was intellectual functioning in the intellectually dis-
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abled range (IQ 70), because adolescents with severe cognitive limitations
might not be able to understand and process the content covered. Adolescents
who were found to have the most extensive trauma histories as assessed by the
YTSI (e.g., physical/sexual abuse, neglect, witnessing community violence)
and difficulty with emotional and behavioral regulation as reported by unit
mental health workers were chosen for participation in the group. Initially, the
group was composed of seven members aged 15 to 17 years old. They were of
varied ethnic backgrounds ( three African Americans, three Caucasians, one
Latino), and they had different psychiatric diagnoses (psychosis, depression,
anxiety, learning, disruptive behavior/conduct disorders, and substance use
disorders). Their family histories differed (e.g., parental/sibling incarceration,
raised by single parent, placed in foster care, have own children/girlfriends
outside of detention), as did their reasons for incarceration (e.g., including
status offenses, gang involvement, attempted murder, assault and battery, and
armed robbery). All of the referred adolescents also reported having engaged
in significant drug use, mostly marijuana, as well as drug selling prior to
incarceration. Given that the group was voluntary, one of the Caucasian
adolescents did not return after the first group session; he indicated that he
was not interested in attending a therapy group. The remaining youths
expressed interest in participating in the group. Finally, two of the adolescents
(1 Caucasian and 1 African American) were released from detention mid-way
through the group. Thus, the group finished with 4 remaining members.
GROUP LEADERS
The group was co-led by two Caucasian therapists, one male and one
female, in their late 20s. Both were advanced graduate students in a local
clinical psychology doctoral program and had extensive graduate-level
training in child/adolescent therapy as well as the effects of trauma
exposure on psychological functioning. The co-leaders were provided with
weekly supervision by a licensed psychologist and faculty member in their
program (3rd author) who specialized in the treatment of trauma and also
had extensive research and clinical experience with delinquent youth.
GROUP FORMAT
The group was conducted for one-hour sessions, twice weekly, over a
period of 12 weeks, totaling 24 sessions. Due to time constraints imposed
by the facility, the entire duration of the original manual (i.e., 25 weeks
with twice-weekly sessions) was not able to be implemented. The group
was held on-site, in a detention center classroom. Security guards were
sometimes stationed inside the classroom and other times outside the
classroom door.
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MANUAL TREATMENT GOALS


The original manualized group intervention focused on three primary
treatment goals. These were helping adolescents to 1) Manage the Moment
(e.g., helping youths manage impulses, emotions, and acute distress more
effectively), 2) Build Coping Strategies (e.g., helping youths strengthen
their long-term ability to cope with the impact of traumatic life experiences
and any associated difficulties), and 3) Enhance Resiliency (e.g., identifying
youths current attempts to successfully manage the results of trauma, and
enhancing those skills to take further steps at buffering extreme stress). A
variety of specific skills were encompassed within each of the three broad
treatment goals, all to assist the youths with more effectively managing the
impact of trauma and resulting emotional and behavioral dysregulation.
INITIAL SESSIONS AND THE IMMEDIATE ROADBLOCKS
ENCOUNTERED
The first one to two sessions were spent adhering relatively closely to
the manual, which devoted two sessions to Welcome and Introduction.
There were discussions and activities designed to orient members to the
purpose of the group, and to develop group rules and rapport among
participants and co-leaders. Almost immediately, the co-therapists realized
that some changes were needed to enhance rapport establishment with this
particular sample of youths, many of whom presented with significant
symptoms consistent with conduct disorder and antisocial personality
disorder. They were not interested in certain activities that they felt to be
hokey or pointless. The following interaction illustrates this point:
Co-Therapist #1 (CT1): So, have you guys ever been in any other
groups like this before?
Group Member #1 (GM1): Yeah, we all have. We have to do these
things all the time.
Co-Therapist #2 (CT2): Oh yeah? Have any of them ever been help-
ful?
GM1: Nope. Mostly we just sit around while some adult tells us what
were doing wrong. The worst is when they make us do these
stupid activities. Itd be better if theyd just keep talking so at
least I could get some sleep.
CT1: Whats the worst activity you guys have ever done? Whats the
activity that, if we did it, would convince you that we are
complete idiots?
GM2: Paper chains, man. One time we had to do fing paper chains
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so we could all learn how great we all are at everything or some


st. That was probably the stupidest thing Ive ever done in my
entire fing life.
GM1: Oh yeah, st man, I did that paper chain thing too! (Group
members all start laughing)
In an effort to maintain the integrity of the manual while adapting the
intervention to the needs of the particular group, the leaders proposed a
more relationally authentic rapport-building activity. It entailed each
group member identifying and verbalizing one good thing about the group
member to their right; this activity was not only received well but spurred
a great deal of discussion among the other group members. They all
reported that none of them had heard directly how their peers positively
perceived them.
As the manual existed at the time, the goal was to move past rapport
building and developing group rules after session two in an effort to begin
providing the group members with psychoeducation about the connection
between trauma exposure and behavioral difficulties and how important it
would be for their future to begin utilizing effective coping skills and
tolerating distress effectively. However, it quickly became clear within two
sessions of adhering to the manual that many of the adolescents were
emotionally disengaged and were taking neither the content nor the
co-therapists seriously. When the co-therapists paused the intervention in
the middle of the third session to reassess what engagement activities were
needed to proceed, a discussion was initiated by one group member. He
focused on how the adolescents felt very different from their Caucasian,
middle-class, professionally dressed, highly educated therapists. They did
not think that the co-therapists could understand their lives or experi-
ences, making the content being discussed irrelevant and impersonal. The
therapists realized at this point that the structure of the manual during the
initial sessions was not designed to address such large cultural discrepan-
cies between therapists and group members. They also realized that the
change/skills-orientation of the intervention, though theoretically well-
grounded and clinically relevant, would not be effective, or even compre-
hensible, until a more authentic therapeutic alliance had been more firmly
established between the co-therapists and the group members.
A Conceptual Reframing of Maladaptive Behavior Patterns
Although the therapists put substantial planning and effort into devel-
oping an authentic relationship with the group, they realized that they had
to reassess their clinical strategy and develop an orthogonal approach to
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account for the youths extreme levels of skepticism and mistrust of the
focus on behavioral change. Ultimately, the therapists determined that they
needed to learn more about the youths lives, to understand what already
worked, and to put aside their agenda as clinicians. They needed to learn
from the youths what type of help was needed. Although the concept of
developing a therapeutic alliance with clients is anything but novel in the
field of mental health, few clinical frameworks incorporate a principle-
driven, acceptance-oriented framework for doing so. There is little guid-
ance about what types of stylistic strategies to use (i.e., how) in deliv-
ering acceptance-oriented interventions with highly treatment-resistant
adolescents, and providing a clinical construct for framing treatment
ambivalence or resistance. Broadly speaking, the stylistic techniques can be
conceptualized as acceptance-oriented (as opposed to change-oriented)
DBT strategies as outlined by Linehan (1993a). The primary set of
acceptance-based strategies in DBT is validation strategies (see Linehan,
1997, for a comprehensive discussion of the definition and function of
validation in psychotherapy). These strategies move beyond empathy-
based interventions to the explicit acknowledgment of the inherent truth
and validity of the clients perspective based on the individuals history and
current circumstances.
Change-oriented strategies, such as problem identification and labelling
and various strategies for enhancing commitment to behavioral change, are
frequently employed in the early phases of treatment when operating from
a DBT framework, especially with difficult to engage, multi-problem
adolescents (see Miller, Rathus & Linehan, 2007). With incarcerated
youths and other juvenile offender populations, heavier doses of accep-
tance with a de-emphasis on change strategies may need to be considered.
This is important given the youths likely history of resisting others
attempts to change their behavior and the invalidating experience of those
attempts to change them. Linehan (1997) noted that validation-based
approaches may be the main intervention approaches early in treat-
ment, and certain clients may require substantially more validation than
other, more change-based intervention strategies throughout treatment.
Our assumption is that incarcerated youths require substantial levels of
validation throughout treatment and (in DBT-language) during the pre-
treatment phase, in which clients commitment to the therapeutic process
is being explored.
Finally, an irreverent communication style (Linehan, 1993a; Miller,
Rathus, and Linehan 2007) proved to be invaluable to the co-therapists
throughout the course of treatment with this group. It appeared to
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sufficiently build and maintain the authenticity of the therapeutic alliance.


It should be noted that while both therapists intentionally used some
irreverent communication strategies from the very beginning of the group,
higher levels of therapeutic irreverence proved necessary. Additionally, it
was their experience that an irreverent therapeutic style alone was not
enough to overcome the need for increased acceptance-oriented strategies
for the development of an authentic therapeutic alliance.
Calling a Do-over: Therapeutic Re-engagement through Acceptance-Based
Strategies
The therapists attempted to validate the group members experi-
ences by focusing the next two sessions on obtaining feedback from
group members about what they would like to talk about and what was
helpful or unhelpful about the intervention. The youths reported what
the therapists had already sensed: Overall, they did not believe that the
therapists could be trusted or that they could really understand them.
Based on these two crucial sessions, the therapists eventually changed
their approach to both the structure and content of the remaining
sessions to one that was more client-centered. Primary interventions
relied on in this phase were drawn from DBT: radical acceptance,
radical genuineness, and significant (yet appropriate) therapist self-
disclosure. A sample paraphrased interaction that occurred during
these two sessions between co-therapists (CT) and group members
(GM) is described below with specific validation strategies as outlined
by Linehan (1993a) in italics:
GM1: Talking about finding ways to stay safe doesnt make any
sense where we come from.
CT1: Seriously? Tell us why (eliciting and reflecting thoughts and
assumptions)
GM1: On the streets, you cant trust anybody, and you never know
when the next thing is going to happen.
GM2: Thats right. I was just walking down the street one day and
watched my friend get shot in a drive-by a block away. I wanted
to go help him,but I had to just turn and run because I knew I
might be next.
CT1: Wow. . . . thats awful (Self-disclosing emotional reaction). Can
you imagine that? (Question directed to CT2)
CT2: Nope. Ill tell you what, I sure never grew up like that (Respecting
differing values).
CT1: Neither did I (Respecting differing values). And if I did, I dont
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think Id believe any of this staying safe stuff either (Irrever-


ently finding the Kernel of Truth).
CT2: I know. I think its amazing you guys even survived all that
(Providing reinforcement and reassurance). How did you do it
(Focusing on the patients capabilities; Eliciting thoughts and
assumptions)?
GM1: You just have to be ready to fight, you know? You cant escape
it, so you just have to never look like youre afraid, or someones
gonna jump you, or worse. You cant ever be weak.
A particularly salient topic during this phase of treatment became
issues of race, class, and socioeconomic status. For instance, an entire
session was devoted to both therapists and group members percep-
tions of each other. The therapists judicious use of self-disclosure
about topics relevant to the youths lives, such as their own familial
financial difficulties and personal challenges, were quite striking to
group members. For example, during a discussion about differences in
socioeconomic status between therapists and group members, it was
discovered that a group member had, as did one of the therapists,
grown up primarily in the New York City area. When the therapist
disclosed that both her parents had been jazz musicians, he replied
genuinely, Oh man, you really were poor! Balancing an acknowl-
edgement of these areas of connection with discussions about the
implications of true and unchangeable differences (such as the advan-
tages of being Caucasian, having grown up in safer neighborhoods, and
having been exposed to better schooling) resulted in a deepening of the
therapeutic alliance. Interestingly, doing so also allowed group mem-
bers to disclose their inaccurate assumptions about the therapists. For
example, when asked to describe what he envisioned the therapists
lives to be like, a group member stated: All I know is that youve both
gotta live in a house on a hill with a white picket fence, and probably
drive a 2003 or 2004 Lexus. The therapists gently disabused group
members of this perception.
AN ACCEPTANCE-ORIENTED RE-APPLICATION OF THE MANUAL
Managing the Moment and Revisiting the Development of Mindfulness
As a component of these new initial sessions focusing on both
acceptance and awareness, the co-therapists asked the adolescents
directly about the coping techniques they already used to disengage
from intensely negative emotions or negative situations. All group
members stated that listening to music served this purpose for them.
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The co-therapists began each group session by playing a song (either


one brought by co-therapists or by group members). They asked group
members to observe and describe, nonjudgmentally, various aspects of
the music (e.g. beat, lyrics, melody, etc.) and its impact on their
thoughts and feelings. Songs were usually requested by the adolescents
and acquired, if necessary, by the co-therapists prior to the group
meetings. Group members quickly became excited about having a
forum to discuss their music, and as treatment progressed, the discus-
sions about the emotional impact of the music deepened. This inter-
vention was similar to the mindfulness exercises discussed in the
Manual without describing it as such to the youth. Exercises using
uncensored Hip-Hop and Rap songs requested by the youths, and
discussing the music (being mindful to withhold any judgments of the
content or nature of the songs), increased awareness and acceptance of
emotions. The music served as highly validating components of the
group for all members. Subsequent discussions were often allowed to
extend much beyond the traditional three to five total minutes usually
allotted to mindfulness activities. At times, the line between the
mindfulness activity and the rest of the group session would become
blurred. Over time, the therapists learned to how to balance the value
of the discussion spurred by the mindfulness activity with the value of
transitioning to another coping skill. They did this by waiting for a
natural point of synergy between the two to arise, and using this
opening to shift the discussion more naturally towards a change and
skills-oriented path. When done optimally, this shift appeared to be
imperceptible to the group members.
Building Coping Strategies: Revisited with Success
As the therapeutic alliance developed and deepened, the co-therapists
began to introduce portions of the manualized approach that focused on
Building Coping Strategies. The initial objective was to increase the
youths awareness of the relationship between their past experiences and
current thoughts, feelings, and actions. However, the co-therapists found
that they needed first to be inherently validating of the youths perspectives
and interpretations of their past experiences, before they could move to
label or teach from a traditional psychoeducational framework. Below is
a paraphrased interaction that occurred during this portion of the treat-
ment, followed by the specific type of DBT validation strategy as defined
by Linehan (1993a):
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CT1: So, how did any of you know that people in your family cared
about you?
GM1: The way I knew my mom loved me was when she put me in my
place. I remember one time, I did something pretty bad, and she
beat me over the head with our answering machine. She was
chasing me all over the house with that thing (laughing). She
beat me pretty bad, too. I think she even broke it, she hit me so
hard (group members laughing).
CT2: You know, I wouldnt have thought about that being a way youd
know your mom loves you. Thats a totally new thing for me to
find out about (Being awake and nonjudgmental to clients expe-
rience).
GM1: Whaddya mean?
CT2: Well, where I came from, that kind of thing would be thought of
as bad to do to kids. That might even be called physical abuse
(Discriminating facts from interpretations). What do you guys
think about that (Eliciting thoughts and assumptions; Providing
opportunities for emotional expression)?
GM2: Naw, you dont get it. Whats really bad is when [your parents]
dont even care what the hell you do. Or when they tell you
youre stupid or worthless or that you never should have been
born.
GM1: Yeah, thats for sure. [Parents] can beat you all they want, but
saying that kind of stuff is whats the hardest to take (group
agreement).
CT2: That actually makes a lot of sense to me (Finding the Kernel of
Truth; Communicating the validity of emotions). That would
really be awful. (Reading emotions, Communicating the validity of
emotions).
Had the therapists challenged the youths initial conceptualization of
parental beatings as love more directly, the group may have missed an
opportunity to discuss the more emotionally painful issue of being inval-
idated by parents through insults or neglect. Moreover, the group mem-
bers were then given enough leeway to validate one another on this
important issue. The therapists did not validate the invalid, that is, they did
not condone physical abuse. Instead, they chose to highlight and validate
a larger humanistic truth for this group of adolescent males: Physical abuse
can be both a signal of parental love, and much less invalidating than the
emotional abuse and neglect that they have endured.
From the therapists perspective, it became clear that frequent use of
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validation and acceptance-oriented strategies was beginning to foster


increasingly more open and non-defensive discussions by the group par-
ticipants. This openness led to a willingness by the youths to participate in
more psychoeducational discussions evaluating the pros and cons of
various behaviors, such as fighting, selling drugs, and gang-related activi-
ties.
A GROUP-INITIATED SHIFT TOWARDS A CHANGE
ORIENTATION
Approximately midway through the course of treatment (session 12 or
so), substantial progress had been made concerning the development of
the therapeutic relationship between the therapists and group members.
The therapists had genuinely learned a substantial amount about the
day-to-day experiences of group members, both while detained and at
home in their families and communities. As discussed above, this had
occurred through the predominant use of a variety of validation and
acceptance-based strategies drawn from a DBT intervention framework.
At this point, a notable shift began to occur, dictated exclusively by the
group members rather than the clinicians. Specifically, they began to
acknowledge that their past behavioral decisions had not always led to
successful or positive outcomes but instead were often quite problematic.
Additionally, they admitted without prompting that many experiences in
their lives were, in fact, things they would never like to experience again.
These types of acknowledgments would not have been possible in the early
stages of treatment. As sessions continued, the adolescents were better able
both to acknowledge the negative long-term outcomes of many of their
maladaptive behaviors and creatively to generate more adaptive behavioral
and cognitive alternatives (e.g., staying away from specific areas of their
neighborhood, engaging in more pleasurable activities, attempting to
consider pros and cons of behaviors in the moment). Opportunities began
to arise for the clinicians to begin safely utilizing more of the psychoedu-
cational, skill-building, and change-oriented strategies outlined in the
manual. Because of the limited remaining course of treatment (approxi-
mately eight weeks), however, certain core concepts were retained while
others were dropped. Core concepts presented and discussed during this
middle phase of treatment from the manual were: 1) The impact of chronic
stress and traumatic experiences on the body and mind, or Unfinished
Emotional Business; 2) Concepts representing the balance between using
logic and emotion in the decision-making process (i.e., Reasonable
Mind, Emotional Mind, and Wise Mind); and 3) Developing the
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skills necessary for identifying and managing intense emotions (i.e., Crisis
Survival Skills). These topics were always presented (a) in the context of
the youths past and current difficult life histories, and (b) with the tone of
clinician curiosity and ambivalence about whether the information being
presented was at all relevant to the youths. It had the effect of strategically
placing the therapists in a collaborative and, at times, deferential relation-
ship with group members. The group had the authority to determine
whether the information might be useful in their lives. Examples used to
frame these concepts were rarely provided by the therapists but were
elicited from the youths whenever possible to ensure that the discussion
context remained ecologically valid and relevant to group members. While
the focus shifted to problem-solving, skill-building, and general change-
oriented frameworks, a much higher proportion of DBT-based irrever-
ence, validation, and acceptance-based interventions continued to be used.
This was more than was suggested in the original manual or than might be
otherwise thought necessary by clinicians unaccustomed to treating ado-
lescents who met criteria for conduct disorder and who had initial
nonverbal presentations as unemotional and relationally disconnected. A
paraphrased interaction during this phase highlights the challenge for the
therapists to balance acceptance and change-oriented strategies with this
population of youths even once therapeutic rapport was established. It was
especially difficult when morally complex and psychologically intense
behavioral content were discussed:
GM4: I could have done a lot more bad things than I already have.
CT1: Like what? (Acceptance-based Intervention: responsive, non-judg-
mental)
GM4: One time my girlfriend cheated on me, and I went back and got
my gun from under the porch. I found the guy down the block
and put the gun to his head, told him he was gonna die. I pulled
the trigger and everything, but it didnt go off. . . . been in the
dirt for too long I guess. After that, I just beat him up instead.
CT2: Wow, thats intense (acceptance-based intervention: Validation of
experience, but clinician unsure whether it is safe yet to move to a
change-based strategy, so he seeks out more information from
acceptance-based stance) . . . Thinking back, are you glad you
didnt shoot him?
GM4: Yeah, guess I got lucky. I knew the whole time I shouldnt kill
him, but I was just so fing pissed off and hurt I guess too that
she did that to me.
CT1: So you wanted to make a different decision, but you were so
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angry it was hard to do. (Acceptance-based intervention: Para-


phrasing clients experience; clarification of emotional and behav-
ioral dysregulation; highlighting the discrepancy between the
youths ideal behavior and actual behavior)
GM4: Yeah, real hard, man. Looking back, I wish I never pulled the
trigger. Its like, man, am I really someone that would kill a
nigga just cause of a girl like that? (GM4 acknowledges regret
and wish that behavior had been different, so change-based
intervention is now possible)
CT1: Its really tough when we feel out of control like that, right
(Acceptance-based intervention: Mind-reading clients emotional
reaction)? (To group members): Leads pretty quick to an emo-
tion mind decision just like GM4 described (clinician preparing
to transition to change-based strategy). What else could have done
to try and manage his anger better in that situation (Change-based
intervention)?
Final Phase: Enhancing Resiliency Revisited
Over the last several sessions of the time-limited treatment, group
content began to focus more on the development of, and reflection
upon, the interpersonal relationships developed between group mem-
bers and co-therapists. Treatment goals during this final phase in-
volved: 1) helping group members learn how to develop and maintain
positive relationships both while detained and upon release, 2) high-
lighting areas of mastery within themselves in order to increase self-
efficacy, and 3) identifying (in as much detail as possible) their plans for
the future and how to achieve them. To do so, several of the original
modules in the manual targeting each of these clinical objectives were
implemented relatively unaltered.
It was particularly useful to have the youth reflect on the development
of their relationships with other group members and the co-therapists.
Issues discussed included how to learn to trust others, how to judge others
intentions and integrity, how much to open up to others, and how to
communicate ones needs and feelings. Specific people to target for healthy
relationships while in detention were identified, and future relationship
planning was discussed to assist the youth with interpersonal goals upon
release. These discussions were frequently frustrating for both the thera-
pists and group members, as together they had to face the fact that they
had very few people in their lives upon whom they could depend for
support and guidance. Additionally, gang-involved group members wres-
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tled with how they could safely minimize their involvement in their gangs
activities. For two group members, death was a very real possibility should
they be perceived at attempting to quit their gang. The group openly
discussed ways that members could stay safely gang-involved while
minimizing their risks for being forced to commit serious and dangerous
crimes. It is clinically noteworthy that the actions for which these youths
were frequently criticized and punished (i.e., lying, manipulating, deceiv-
ing, and misleading others) can be adaptive and potentially lifesaving.
Given that most of the group members had few life experiences of
feeling efficacious or self-valuing, helping these members identify areas of
mastery to increase self-efficacy proved to be quite challenging. One youth
painfully discussed the ways teachers had reportedly called him names,
such as stupid, retarded, worthless, and a waste to society.
Validation of this youths experience became complicated because he
clearly believed that these teachers were correct in their reported assess-
ment of his lack of educational potential. As a result, the co-therapists
needed to frequently present objective evidence to this youth (e.g., high
levels of authentic praise for an insightful comment) to counteract the
cumulative effects of these educational experiences.
Another hurdle related to improving these youths low self-efficacy was
their extreme ambivalence about creative self-expression for fear of being
rejected by the co-therapists and other group members. For instance, two
of the group members were encouraged to bring in their artistic work, such
as rap lyrics and drawings, for group discussion. This was clearly consid-
ered an extremely emotionally-risky action for them; in fact, many of the
youths resisted doing this for several weeks. When they shared their art
forms with the group, each member demonstrated strikingly anxious
nonverbal behavior. Each appeared extremely surprised and relieved when
his work was received in a unanimously positive manner by the co-
therapists and other group members. The unfolding of this process
appeared authentically validating and helped to build both self-efficacy
and group cohesion. Particularly in this final phase of treatment, the
co-therapists attempted to strike a fine balance between DBT-oriented
reciprocal and irreverent communication strategies as a means for mini-
mizing the obvious anxiety associated with such risky self-expression. A
brief, paraphrased excerpt of one validating interaction is described below
(labels of the example stylistic strategies used to enhance rapport and
increase resiliency are included):
CT1: (Clinician looking at horror-movie style clown face drawing, with
a sword through his head, one eye all black, the other eye clear,
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etc.) Wow, you have really got some talent going on here
(Responsiveness and Warm engagement).
GM3: No way, youre just bullsting me.
CT2: No bullst here, sir (Reframing in an unorthodox manner).
Theres no way I could draw like that. Look at all the details
you really took your time with this, and obviously know what
youre doing (Expressing impotence and omnipotence).
GM3: This is why all my teachers said I was a worthless human being.
All I could think about in school was drawing this stuff, so thats
all I did. Everyone said [drawing like this all the time] proved I
was stupid, because it showed I couldnt learn anything. (Hes-
itates). . . . What do you like about it?
CT2: (Thinks for a minute while staring at the picture): The eyes the
eyes are my favorite part of the whole drawing. It seems like
youre really trying to say something with the eyes (Responsive-
ness, Genuineness; Oscillating intensity and using silence).
GM3: Yeah, the eyes. . . . thats my favorite part too. I worked real
hard on the eyes.
The Final Session
The therapists took great care preparing for the final group session.
They carefully structured it to maximize the functional and explicit
validation of the youths as individuals, as a group and with particular
regard to their progress throughout the 12-week treatment. In the first
half of the session, the therapists gave the adolescents feedback as a
group. To emphasize the interpersonal aspects of the treatment and to
highlight the youths potential for positive impact on others, feedback
focused not on the adolescents performance, but on the impact that
each group member had made on each of the co-therapists both
personally and professionally. This feedback was received extremely
well by the group members, who appeared highly surprised that they
could have such an effect. Consistent with the Manuals recommenda-
tion, group members were given signed Certificates of Completion.
All four youths completing the group reported surprise and apprecia-
tion for this and reported that it was the first time any of them had ever
received a certificate or award of any kind.
During the second portion of the session, the co-therapists spent 15
minutes with each youth separately. Each youth was presented with a small
gift (such as themed magazines, a specific book, or voice recorder for a
youth with a talent for rapping) based on his interests discovered through
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the group process, and individualized cards from each therapist. The cards
described in detail the therapists appreciation, view of the youths growth
over the course of treatment, and strengths (and challenges) to be antici-
pated as they move forward in their lives. This portion of the session was
particularly moving for both therapists. The youths gave intimate and
sometimes striking feedback, such as Youve helped me to feel again,
and Youre the first people to never make me feel like Im stupid.
CLINICAL IMPLICATIONS AND FUTURE DIRECTIONS
As members of the treatment group poignantly reminded us, authen-
tically engaging youths with a history of repeated, pervasive trauma and
conduct disorder on a human level is essential, albeit often challenging.
Given the past behaviors, sometimes intimidating interpersonal presenta-
tions, and profound distrust of this group, we found that engagement is
greatly facilitated by using acceptance-oriented strategies (such as those in
DBT) to maintain high clinical attunement to the therapeutic alliance
throughout treatment. We posit that these interventions are necessary,
regardless of the specific clinical framework or therapeutic modality being
used.
Although authentic human engagement was a necessary component
of this treatment course, this factor alone was not sufficient to explain
the clinical movement seen and described in this particular clinical case
example. Skills-based, change-oriented approaches were also necessary
and were explicitly and spontaneously requested by the youths once the
alliance had been established. The youths with whom we worked
presented with substantial skills deficits across a variety of psychosocial
and behavioral domains, such as emotion dysregulation, reduced sense
of identity and life meaning, behavioral impulsivity, and significant
prosocial skills deficits, which were consistent with a complex or
developmental trauma framework. Without implementing skills-based
treatment components, these youths would have developed no new
psychological or behavioral tools for managing their extremely chal-
lenging lives both during and after detention.
Although many evidence-based treatments inherently focus on
change, very few of these treatment manuals have actually elaborated
on how critical acceptance and validation strategies are to the facilita-
tion of such change. In the last two decades, more empirically-sup-
ported treatments have begun to formally acknowledge the importance
of balancing change with acceptance-based strategies, including Dia-
lectical Behavior Therapy (Linehan, 1993a), Motivational Interviewing
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(Miller and Rollnick, 2012), and Acceptance and Commitment Therapy


(Hayes, Strosahl, & Wilson, 2011). We encourage clinical researchers,
especially those who work with multi-problem clients and adolescents,
to continue to attend to and refine acceptance-based strategies for their
use in all stages of treatment.
Finally, research identifying effective interventions for behaviorally
disordered youths who have complex PTSD and are in restricted settings
is greatly needed. We posit that one possible starting point for such
research should be adaptations of existing, empirically informed or em-
pirically-supported treatments, such as SPARCS and DBT. We recom-
mend the incorporation of principle-driven guidelines and relationally
based clinical markers for the establishment of a strong working therapeu-
tic alliance prior to moving into primarily change and skills-oriented
treatment phases of these existing interventions. However, other creative
approaches should also be explored.
A member of the juvenile detention staff reported to the co-therapists
that the group member who stated, you helped me feel again, was
stabbed in the chest at a party and nearly killed just a few weeks after being
discharged from juvenile detention. Solutions to the problem of how to
effect meaningful change with youths such as the young men described in
this paper cannot arrive fast enough. Without purposeful and urgent
attention, young men like those described in this paper, who are some of
the most marginalized, traumatized, and socially costly youths in our
country, will remain inadequately treated and will have little hope of
meaningful re-entry into mainstream society.

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