Dialectical Behavior Therapy for Adolescents With Multiple Problems
In Dialectical Behavior Therapy for Adolescents With Multiple Problems, Alec L. Miller demonstrates this compassionate, principle-based therapy for clients who have difficulty regulating emotions and behaviors. Emotional dysregulation is common among adolescents, often leading them to self-injurious behavior, including suicide. Studies have shown that dialectical behavior therapy can significantly reduce suicide attempts and help adolescent clients deal with multiple problems.
In this session, Dr. Miller works with a 17-year-old boy who is depressed, abusing marijuana, and who has recently contemplated suicide. Dr. Miller highlights the client's strengths while trying to obtain commitment to treatment in order to reduce his depression and marijuana use and build a life worth living.
Adolescent suicide is a major public health problem and accounts for at least 100,000 annual deaths in young people world-wide (World Health Organization, 2001). In the United States, suicide accounts for more adolescent deaths than all natural causes combined, with more than 2,000 dying by suicide per year (Anderson, 2002). Suicide ranked as the third leading cause of death among the 10- to 14-year-old and 15- to 19-year-old age groups in the United States in 2000, preceded only by accidents and homicide (Anderson, 2002). Nearly twenty percent of middle school and high school aged adolescents report having seriously considered attempting suicide during the past year (Grunbaum et al., 2002).
Dialectical Behavior Therapy (DBT) is a compassionate, principle-based psychotherapy for suicidal multiproblem, multidiagnostic individuals who have significant difficulty regulating emotions and behaviors. Developed by Marsha Linehan, DBT was first introduced over a dozen years ago as a treatment for suicidal and self-injurious individuals diagnosed with borderline personality disorder (BPD).
In Linehan's first randomized, controlled trial involving outpatient suicidal adult women with BPD, DBT significantly reduced inpatient psychiatric days and suicide attempts and improved global social adjustments and treatment compliance (Linehan et al., 1991). Since then, nine more randomized controlled studies conducted at different research centers around the world have demonstrated DBT to be an effective treatment for multiproblem individuals diagnosed with BPD. Both the American Psychological Association and the American Psychiatric Association currently consider DBT to be a first-line treatment for BPD.
As a result of DBT's success in treating adults with BPD, Dr. Alec Miller and his colleagues have spent the past 12 years researching and adapting DBT for suicidal and self-injurious multiproblem adolescents and their families. Based on their clinical research (Miller et al., 1996; Rathus & Miller, 2002), the American Academy of Child and Adolescent Psychiatry recommends considering DBT as a treatment with suicidal adolescents (2001). DBT has also been modified for use with other psychological problems such as eating disorders and substance use.
DBT blends standard cognitive–behavioral therapy with Eastern philosophy and meditation practices and shares elements with psychodynamic, client-centered, Gestalt, paradoxical and strategic approaches (Koerner, Miller, & Wagner, 1998).
Domains of Dysregulation
A person diagnosed with BPD tends to exhibit problems in 5 domains. According to Linehan, the main problem for these patients is emotional dysregulation. Consequently, these individuals struggle with anger and emotional lability. These difficulties can contribute to interpersonal dysregulation where he or she struggles with fears of abandonment and chaotic relationships. Mood and relationship instabilities often lead to self-dysregulation and confusion about one's identity, values, and feelings in addition to a chronic sense of emptiness. Cognitive dysregulation in the form of rigid thinking, irrational beliefs, paranoid ideation and dissociation may also occur. Finally, as a consequence of, or as an attempt to resolve, dysregulated emotions, behavioral dysregulation in the form of impulsivity and suicidality are often seen (Koerner, Miller, & Wagner, 1998).
DBT skills training addresses five problem areas with corresponding behavioral skills modules (Miller, Rathus, & Linehan, 2007). The core mindfulness skills module addresses self-dysregulation. Often BPD patients find themselves making emotional choices. In order to enable them to use both emotional and rational input to make balanced (labeled "wise mind") decisions, these patients are taught to use a number of skills (e.g., nonjudgmental observing of the experience and then putting it into words) to help transition from "emotional mind" to "wise mind".
Distress tolerance skills target behavioral dysregulation.
Both crisis survival skills (i.e., distracting oneself, self-soothing using the five senses, making a list of pros and cons) and radical acceptance skills help the patient tolerate seemingly intolerable, painful circumstances without engaging in impulsive behavior like suicide, or high-risk sexual, substance-related, or other dangerous behaviors.
The emotion regulation skills module addresses emotional dysregulation. The individual is taught how to reduce emotional vulnerability, increase positive experiences (resulting in positive emotions), and change current emotions by acting in opposite ways.
The interpersonal effectiveness skills module teaches the individual how to negotiate for what she wants while maintaining good relationships in addition to her self-respect.
Finally, a fifth skills module, called Walking the Middle Path Skills, addresses the need to enhance validation skills, learning principles (such as positive reinforcement), and finding a middle path on the dialectical dilemmas that are inherent in these families (e.g., balancing "too strict" with "too loose").
The Structure of DBT
Linehan described five functions of comprehensive treatment in the management of multi-problem patients (Linehan, 1993). These five functions guide the structure of DBT:
- Enhancing the patient's capabilities
- Improving the motivation to change
- Ensuring that new capabilities are generalized from therapy to the patient's every day life
- Enhancing the therapist's capabilities and motivation to treat patients effectively
- Structuring the environment to support the patient' and therapist's capabilities
Miller, Rathus, and Linehan (2007) describe various adolescent programs in their book; however, they require adolescents and families in their outpatient DBT program to commit to 16 weeks of treatment during which the patient participates in a weekly psychoeducational skills training group (Function 1); meets weekly with an individual therapist to identify and reduce factors that interfere with the ability to use skills (Function 2); and contacts the therapist by phone on an as-needed basis when crises arise, thus facilitating generalization through these in-vivo interactions (Function 3).
The therapist in turn commits to a specified length of treatment during which he or she participates in a weekly therapist consultation group that offers both technical help and emotional support (Function 4).
Finally, the environment may need to be structured, for example, to ensure the patient does not have to get worse to obtain additional help and that therapists have reasonable time-demands to prevent burn-out (Function 5; Koerner, Miller, & Wagner, 1998). Family therapy sessions are periodically scheduled on an as-needed basis to improve family communication and support and to provide an opportunity to teach, model and coach skills that can be generalized in this context.
As stated previously, within DBT, the main problem to be treated in BPD is emotional dysregulation. Most extreme behavior is conceptualized as either a result of emotional dysregulation or as an attempt to regulate emotion. One must seek out the nature and etiology of the patient's emotional dysregulation in order to understand the function of the maladaptive behavior. The major task of therapy is helping the patient suppress, block, or prevent these maladaptive solutions while concurrently strengthening alternate adaptive behaviors in a manner that ensures they are generalized to all relevant contexts. DBT seeks to accomplish these goals through balancing change and acceptance strategies.
As with other behavioral therapies, DBT views problem behavior in terms of deficiencies in adaptive behavior. Behavior is seen as relevant in itself and treatment therefore focuses on capability enhancement. When faced with a problem behavior, the primary task for the therapist and patient is to conduct a thorough behavioral analysis. The chain of events leading up to the behavior, the patient's responses (i.e., behavioral, emotional, cognitive) and the environment's responses to the behavior are detailed in order to identify triggers and consequences that maintain the behavior (Koerner, Miller, & Wagner, 1998). With each suicidal event a behavioral analysis is conducted until the patient can see for herself the patterns of stimulus–response.
Next, alternate response chains are explored. The therapist must assess whether the patient has the skills to cope effectively? If the answer is no, then capability enhancement strategies are used. The DBT skills modules teach skills needed for effective emotional, cognitive, behavioral, and interpersonal regulation. If the patient does have the skills, then a number of other variables are examined.
First, faulty beliefs may interfere with the use of skillful responses and so cognitive restructuring strategies are used. Second, if conditioned emotional responses are blocking adaptive behavior, exposure-based strategies are needed. Third, the environment may either fail to reinforce functional behavior or reinforce dysfunctional behavior; then contingency management strategies are indicated. Fourth, if issues in the patient–therapist relationship are deemed contributory, relationship strategies are needed. Fifth, help from the environment may be required for resolution (e.g., financial assistance, brief hospitalization) and so consultant strategies must be used. Finally, although a patient may use a skill easily in the therapy room, it may be much more difficult in the midst of a suicidal crisis; thus, as previously mentioned, he or she must learn to generalize their repertoire of skills to various contexts.
Like all other psychotherapies, DBT emphasizes empathy and adds to it validation. Validation communicates the therapist's active acceptance of the patient. It also serves to balance change strategies as well as to teach self-validation through modeling. Validation not only communicates an understanding of the other's responses but it also attempts to make order out of chaos. It seeks to help the patient and therapist understand the patient's responses in terms of the range of human responses in the context of the individual patient. Although validation does not mean making valid what is invalid, the DBT therapist searches for some aspect of validity within even the most extreme of responses. For example, slashing may be valid because it relieves tension in the short-term (although it is invalid in the long-term because it interferes with the goal of building a life worth living; Linehan, 1997).
It is important to distinguish between positive reinforcement and validation. For example, a patient has been utilizing his or her skills and not engaging in maladaptive behavior but remains depressed and struggling with emotional dysregulation. The therapist may note the utilization of skills and positively reinforce the patient for her functioning with a comment such as, "You handled that well, good job." Despite the positive reinforcement, the patient can feel invalidated in this situation as he or she may feel that their level of distress is not understood. In situations such as this it is appropriate to reinforce the patient for her adaptive functioning but to add a validating comment such as, "I understand that you still are not feeling well but you handled that situation well, good job."
Why Employ DBT with Adolescents
When faced with a suicidal teenager, there is often a sense of confusion and fear about where to begin treatment, as multiple serious problems seem to all require attention simultaneously. In DBT, the treatment is structured to guide the focus to the appropriate area based on a predetermined treatment hierarchy. The therapist then uses multimodal interventions to flexibly address the multiple problems.
DBT targets the high-risk suicidal youth who are often excluded from treatment trials and makes the behavior the primary target. It includes those with BPD or BPD symptoms, especially impulsive aggression, and provides for those with comorbid illness. DBT also allows for the treatment of concurrent substance abuse and has in fact been modified for adults with primary substance abuse problems and BPD (Linehan et al., 1998).
In addition to the features described above, DBT has other features that suggest it can be effectively adapted for suicidal adolescents. DBT directly targets treatment noncompliance and focuses on keeping adolescents engaged in therapy. There are also problem areas that are addressed in DBT (i.e., emotional instability, impulsivity, interpersonal problems, and confusion about oneself) that correspond to developmental tasks of adolescence.
Miller and colleagues (2007) believe DBT is most appropriate for those suicidal teens who exhibit a more chronic form of emotional dysregulation with numerous coexisting problems (some will meet criteria for BPD and others will not, as alluded to above). For example, Miller and Taylor (2005) found in their analysis of the 1999 Youth Risk Behavior Survey data that the more problem behaviors an adolescent has, the greater the risk of suicidal behavior. Compared to adolescents with zero problem behaviors (such as violent behavior, binge drinking, cigarette smoking, high risk sexual behavior, disturbed eating behavior, or illicit drug use), the odds of a medically treated suicide attempt increased exponentially with the addition of each new problem behavior, culminating with a 277.3 times greater risk with six problem behaviors present (Miller, Rathus, & Linehan, 2007).
Alec L. Miller, PsyD, received his bachelor of arts degree from the University of Michigan in Ann Arbor before earning his doctorate in clinical psychology from the Ferkauf Graduate School of Psychology of Yeshiva University. Dr. Miller has become internationally known in the areas of adolescent depression, suicidology and self-injury, borderline personality disorder, and dialectical behavior therapy (DBT).
He has spent the past 13 years heading a clinical research team adapting DBT for outpatient suicidal multiproblem adolescents, as well as contributing to the adaptation of DBT for inpatient suicidal adolescents, delivery of DBT in high schools to at-risk youth, and DBT adapted for a triply diagnosed adult population (i.e., HIV/AIDS, substance abuse, and BPD). He has received federal, state, and private funding for his research.
He has authored and coauthored dozens of articles and book chapters on these and related topics and is first author of the book Dialectical Behavior Therapy with Suicidal Adolescents, published by Guilford Press (2007). He also coauthored Childhood Maltreatment, Advances in Psychotherapy-Evidence Based Practice (2006). He is frequently invited to conduct lectures and workshops to both lay and professional audiences and has trained thousands of mental health professionals around the world. In 2002, he received the Service Award from the International Society for the Improvement and Training of DBT (ISITDBT) and was chair of the 2004 and 2005 ISITDBT Conferences.
As a clinician, Dr. Miller is cofounder of Cognitive and Behavioral Consultants of Westchester, LLP, a private group practice in White Plains, NY. He is highly sought after as a leading practitioner of CBT and DBT with children, adolescents, and adults. He also consults to various agencies and grant-funded programs, some of whom conduct DBT in outpatient, inpatient, and school settings.
His clinical expertise has been highlighted by various popular media outlets including CNN Paula Zahn Now, CBS-TV Morning News, Teen People Magazine, and the NY Daily News. One PBS program, Keeping Kids Healthy, in which Dr. Miller and one of his young adult patients were interviewed about adolescent suicidality, was nominated for an Emmy Award.
Dr. Miller is a fellow of the American Psychological Association (APA), past president of the APA's Division 12 (Society of Clinical Psychology) section on Clinical Emergencies and Crises, and Division 12 program chair for the 2007 APA Convention. He has also been an invited expert at National Institute of Mental Health consensus meetings regarding the assessment of and intervention for suicidal behavior.
Dr. Miller has spent the past several years consulting to the Food and Drug Administration on the "Suicidality Classification Project" to help further examine what relationship exists between pharmacotherapy and suicide in children and adults. Finally, Dr. Miller currently serves as associate editor for the journal of Cognitive and Behavioral Practice and serves as a reviewer for several other professional journals.
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- Woodberry, K,, Miller, A. L., Glinski, J., Indik, J., & Mitchell, A. (2002). Family therapy and dialectical behavior with adolescents: Part 2. A theoretical review. American Journal of Psychotherapy, 56( 4), 585–602.
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