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SPECIAL ISSUE
DIALECTICAL BEHAVIOR THERAPY:
EVOLUTION AND ADAPTATIONS IN THE 21ST
CENTURY
EDITOR-IN-CHIEF
BRUCE J. SCHWARTZ
DEPUTY EDITOR
SCOTT WETZLER
ASSOCIATE EDITORS
SALVATORE LOMONACO
JERALD KAY
ALLAN TASMAN
EDITORIAL BOARD
AARON T. BECK G.J. SARWER-FONER
ANN W. BURGESS THEODORE SHAPIRO
RICHARD D. CHESSICK ROBERT D. STOLOROW
ROBERT COLES GEORGE E. VAILLANT
PAUL CRITS-CHRISTOPH PAUL L. WACHTEL
HOWARD C. CUTLER STANLEY L. WITKIN
HABIB DAVANLOO JESSE H. WRIGHT
RICHARD DAYRINGER JOEL YAGER
MORRIS EAGLE IRVIN YALOM
TRACY EELLS
GLEN O. GABBARD EDITOR-IN-CHIEF EMERITUS
JAMES S. GROTSTEIN T. BYRAM KARASU
SEYMOUR HALLECK
SYLVIA R. KARASU Book Review Editor Emerita
OTTO KERNBERG SOPHIE FREUD
PETER D. KRAMER
ARNOLD M. LUDWIG
Editorial Executive
JOHN MARKOWITZ
TINA M. BONANNO
W. WALTER MENNINGER
ROBERT MICHELS
THOMAS MOORE Publication Manager
JOHN NORCROSS ANGELA GROSSO-TOSCANO
ANNA ORNSTEIN
FRED PINE Accounting Assistant
JUDITH L. RAPOPORT DEBBIE SANTANA
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.
GENERAL INFORMATION
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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
92
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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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
94
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
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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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.
98
Evolution of DBT
Figure 1
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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AMERICAN JOURNAL OF PSYCHOTHERAPY
Figure 2
DEARMAN ACRONYM FROM INTERPERSONAL EFFECTIVENESS MODULE
Figure 3
TIP ACRONYM FROM DISTRESS TOLERANCE MODULE
106
Evolution of DBT
Figure 4
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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Staats, A. W. & Staats, C. K. (1963). Complex human behavior. New York: Holt, Rinehart & Win.
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Transdiagnostic Applications of DBT for
Adolescents and Adults
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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AMERICAN JOURNAL OF PSYCHOTHERAPY
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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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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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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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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Dialectical Behavior Therapy and Eating
Disorders: The Use of Contingency
Management Procedures to Manage
Dialectical Dilemmas
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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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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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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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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Radically Open-Dialectical Behavior
Therapy for Disorders of Over-Control:
Signaling Matters
INTRODUCTION
Until recently, the majority of treatment interventions targeting per-
sonality disorders (PDs), including standard dialectical behavior therapy
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Figure 1.
A NEUROBIOSOCIAL THEORY FOR OVER-CONTROLLED DISORDERS
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
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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AMERICAN JOURNAL OF PSYCHOTHERAPY
Figure 2.
RO-DBT INDIVIDUAL TREATMENT TARGET HIERARCHY FOR OVER-CONTROL
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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Radically Open-DBT for Over-control: Signaling Matters
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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Radically Open-DBT for Over-control: Signaling Matters
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
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Treatment Acceptability Study of Walking
The Middle Path, a New DBT Skills
Module for Adolescents and their Families
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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Treatment Acceptabilty Study
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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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
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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AMERICAN JOURNAL OF PSYCHOTHERAPY
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
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Treatment Acceptabilty Study
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
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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Dialectical Behavior Therapy for Suicidal
Latina Adolescents: Supplemental
Dialectical Corollaries and
Treatment Targets
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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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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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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DBT for Suicidal Latina Adolescents
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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DBT for Suicidal Latina Adolescents
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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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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Acknowledgement: The authors wish to thank Elizabeth Courtney-Seidler, PhD, for her help in
reviewing the manuscript.
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Therapy
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-
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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
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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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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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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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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
*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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Adapting Trauma Treatment For Incarcerated Adolescents
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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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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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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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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Adapting Trauma Treatment For Incarcerated Adolescents
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,
234
Adapting Trauma Treatment For Incarcerated Adolescents
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
235
AMERICAN JOURNAL OF PSYCHOTHERAPY
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
236
Adapting Trauma Treatment For Incarcerated Adolescents
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