Academic journal article American Journal of Psychotherapy

Treatment Acceptability Study of Walking the Middle Path, a New DBT Skills Module for Adolescents and Their Families

Academic journal article American Journal of Psychotherapy

Treatment Acceptability Study of Walking the Middle Path, a New DBT Skills Module for Adolescents and Their Families

Article excerpt


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 (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.

Miller's and Rathus' modifications maintain the theoretical and structural 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 treatment's effectiveness with this population (e.g., Goldstein, 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 (Linehan, 1993). Alternating between extreme behaviors represents an attempt to correct intense emotional dysregulation. However, because these extreme 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 Linehan's (1993) dialectical dilemmas are applicable to this population, Rathus and Miller's dilemmas highlight the unique interaction patterns of troubled adolescents and their families. The adolescentfamily dialectical dilemmas are 1) excessive leniency versus authoritarian control, 2) pathologizing normative behaviors versus normalizing pathological 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 adolescentfamily 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 adolescentfamily dilemmas. Walking the middle path also highlights two skill areas 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; Linehan's (1993) biosocial theory of borderline personality disorder suggests that individuals 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. …

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