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