Academic journal article American Journal of Psychotherapy

Family Therapy and Dialectical Behavior Therapy with Adolescents: Part II: A Theoretical Review

Academic journal article American Journal of Psychotherapy

Family Therapy and Dialectical Behavior Therapy with Adolescents: Part II: A Theoretical Review

Article excerpt

Dialectical Behavior Therapy (DBT) is based on a transactional model of the etiology of borderline personality disorder (BPD). It assumes that the associated emotional dysregulation is not simply biological or family induced but the result of a dynamic interaction between the biology and characteristics of an individual with the individual's social environment. This paper discusses the theoretical issues and empirical research relating to a synthesis of family therapy and DBT with adolescents. A review of the literature identifies support for a greater understanding and inclusion of families in treatment, attention to relational aspects of affect, and a dialectical framework for synthesizing individual-oriented and systemic-oriented theories and practice. Some implications for the development of a DBT family therapy model are discussed.

Dialectical Behavior Therapy (DBT) is an empirically supported principle-- driven psychotherapy for adult women with borderline personality disorder (1, 2) that has been adapted for multiproblem, suicidal adolescents. Among these adaptations (e.g., simplified and shortened skills-training curricula, multifamily group format for skills training), none has posed as significant a theoretical and structural challenge for therapists as the integration of family therapy. Pilot research with an adolescent population has shown promise (3), but much more research is needed to clarify which adolescents benefit from DBT and what the indicators are for specific modifications, such as family therapy. This is especially true given the interest among professionals treating adolescents in applying DBT to a broad range of diagnostic groups within varied settings (e.g., outpatient, inpatient, residential, day treatment). This paper discusses the theoretical issues of synthesizing family therapy and DBT with adolescents as a step toward the development of a testable treatment model.

DBT's biosocial theory of the etiology and maintenance of borderline personality disorder (BPD) attributes the emotional, cognitive, and behavioral dysregulation to a transactional process between an "emotionally vulnerable" individual and an "invalidating environment." An emotionally vulnerable individual has high emotional sensitivity, reactivity, and a slow return to the baseline emotional state. An invalidating environment is one in which an individual's expression of private experience is rejected and treated as wrong or condemned for socially unacceptable personality traits. It can include punishment of emotional displays, intermittent reinforcement of emotional escalation, or the oversimplification of solving life's problems (4). In contrast to suicidal adults, suicidal adolescents are likely to live with, or under the authority and regular influence of, their families, and experience their families as invalidating environments. The transactions between the adolescent and family thus become an important focus of treatment.

This paper begins by highlighting the primary considerations supporting a synthesis of family therapy and DBT with adolescents. It then reviews the literature and theoretical base for this synthesis and direct treatment of the transactional processes presumed to generate and maintain emotional dysregulation and parasuicidality. The authors review research on family involvement in treatment, family factors that contribute to, or protect against, emotional and behavioral problems, such as suicidality, and specific family interventions and empirical research with depressed, suicidal, and multiproblem adolescents. Finally, this paper summarizes some of the implications of this literature on developing a DBT family therapy model with adolescents.

CONSIDERATIONS IN SYNTHESIZING FAMILY THERAPY AND DBT WITH ADOLESCENTS

Minors Require Changes in the Adult DBT Model

DBT has traditionally focused on intervening at the individual level to impact change, emphasizing "consultation-to-the-patient" regarding effective interaction with the individual's environment. …

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