Spring 2003 Newsletter Section 7

Dialectical Behavior Therapy (DBT) was created by Linehan (1, 2) as a treatment for the chronically parasuicidal woman diagnosed with borderline personality disorder (BPD). Parasuicide is defined to be any acute, intentionally self-injurious behavior resulting in physical harm, with or without intent to die (1). Miller and colleagues (3) adapted DBT for use with adolescents due to its primary treatment targets aimed at reducing life threatening and quality of life interfering behaviors, as well as its specific focus on treatment engagement and retention (8). Furthermore, this adaptation has placed a greater emphasis on family involvement than standard DBT (4).

Based on the biosocial theory, DBT posits that BPD is caused by pervasive emotional dysregulation (1). Emotion dysregulation is believed to be the result of a transaction between an individual who is biologically predisposed to having difficulty regulating emotion and an environment that intensifies that vulnerability (1, 2, 4). In other words, this theory suggests that borderline personality symptomatology, including, parasuicidal behavior, may result when an adolescent who is biologically emotionally vulnerable is placed in an invalidating environment, one that chronically communicates to the child that his/her reactions, feelings, thoughts or responses are faulty, inaccurate or otherwise invalid (1, 4). Therefore, parasuicidality may serve to regulate affect as well as elicit help from an otherwise invalidating environment.

When working with adolescents, involving family members is frequently a key component to the treatment. While family members are involved in DBT through collateral sessions and skills training, only recently have treatment developers begun to highlight the importance of incorporating family therapy into DBT in a more synthesized manner (5). According to Miller and colleagues, this modality may in fact have a unique ability to reduce the invalidation considered to be a major contributor to emotion dysregulation and BPD, in general (5).

DBT treatment strategies are based on a dialectic philosophy that views reality as an interactive system comprised of opposing internal forces that exist in a state of continuous change (1, 5). The core dialectic of the treatment balances acceptance of the client and the simultaneous need for change (1, 4). Therapists who work with adolescents and their families can use the concept of dialectics as a guide which can help to navigate the multiple perspectives presented during family sessions (5) and increase understanding of all sides of a conflict.
One way in which this can be done is through the use of validation. Linehan states that validation strategies require „the therapist to search for, recognize and reflect to the client the validity inherent in his/her response to events. With unruly children, parents have to catch them while they're good in order to reinforce their behavior; similarly, the therapist has to uncover the validity within the client's response, sometimes amplify it, and then reinforce it" (8).

Linehan proposed six levels of validation, which include: listening nonjudgmentally, accurate reflection, mind-reading, or articulating unspoken thoughts and feelings, understanding the historical background of a behavior, confirming thoughts, behaviors and feelings based on current circumstances and radical genuineness, which requires the therapist to speak authentically to the patient and his/her family (6, 7). These levels are explained in further detail elsewhere (7).

Validation can be as useful with families as with individuals both to help the therapist appreciate and recognize a family's unique experience and to ultimately foster change (7). DBT therapists employ a non-pejorative stance with families of borderline adolescents who often report having been blamed and judged by mental health professionals in settings previously. To be clear, validation does not mean agreeing with everything or validating the invalid (5) within the family therapy relationship. It does, however, provide the basis for a strong therapeutic alliance while look for and validate the kernel of truth in each family members' perspective.

References
1. Linehan, MM (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.

2. Linehan, MM (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.

3. Miller, AL, Rathus, JH, Linehan, MM, Wetzler, S, & Leigh, E. (1997). Dialectical behavior therapy adapted for suicidal adolescents, Journal of Practical Psychiatry and Behavioral Health, 3, 78-86.

4. Miller, AL (1999). Dialectical behavior therapy: A new treatment approach for suicidal adolescents, American Journal of Psychotherapy, 53, 413-417.

5. Miller, AL, Glinski, J, Woodberry, KA, Mitchell, AG, Indik, J. (2002). Family therapy and dialectical behavior therapy with adolescents: Part I: Proposing a clinical synthesis, American Journal of Psychotherapy, 56, 568-584.

6. Linehan, MM (1997). Validation and psychotherapy. In A Bohart & C. Greenberg (Eds.) Empathy reconsidered: New Directions. Washington DC: APA

7. Woodberry, KA, Miller, AL, Glinski, J, Indik, J, & Mitchell, AG (2002). Family therapy and dialectical behavior therapy with adolescents: Part II: A theoretical review, American Journal of Psychotherapy, 56, 585-602.

8. Linehan, MM (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press, pp. 222-223.

Miller, AL, Nathan, JS, & Wagner, EE (In press). Engaging suicidal multi-problem adolescents with DBT. In David Castro-Blanco (Ed.), Treatment Engagement with Hi-Risk Adolescents: Empirically Based Treatments, Washington, DC: American Psychological Association Press