DBT A

Dialectical Behavior Therapy With
Adolescents
Dialectical Behavior Therapy With Adolescents is an essential, user-friendly guide

for clinicians who wish to implement DBT for adolescents into their practices. The
authors draw on current literature on DBT adaptation to provide detailed descriptions
and sample group-therapy formats for a variety of circumstances. Each chapter includes
material to help clinicians adapt DBT for specific clinical situations (including
outpatient, inpatient, partial hospitalization, school, and juvenile-detention settings)
and diagnoses (such as substance use, eating disorders, and behavioral disorders). The
book’s final section contains additional resources and handouts to allow clinicians to
customize their treatment strategies.
K. Michelle Hunnicutt Hollenbaugh, PhD, LPC-S, is an associate professor in the

Department of Counseling and Educational Psychology at Texas A&M University,
Corpus Christi. She has several years of clinical experience in a variety of settings and
has spent the majority of this time researching and providing Dialectical Behavior
Therapy (DBT). She is currently conducting several research studies on adaptations of
DBT and continues to facilitate the implementation of DBT-based clinical services for
the local community.
Michael S. Lewis, PhD, LPCC-S, is a clinical professor at Capital University and

has extensive experience working with adolescents and young adults. He has also
spent time working in substance-abuse treatment facilities and high-school settings.
Michael specializes in wellness- and mindfulness-based innovative interventions. His
research interests include college counseling, counselor development, and behavioral
addictions.
Dialectical Behavior Therapy
With Adolescents
Settings, Treatments, and Diagnoses
K. Michelle Hunnicutt Hollenbaugh

Michael S. Lewis
First published 2018
by Routledge
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© 2018 K. Michelle Hunnicutt Hollenbaugh and Michael S. Lewis
The right of K. Michelle Hunnicutt Hollenbaugh and Michael S. Lewis to be identified as
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and are used only for identification and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Names: Hollenbaugh, K. Michelle Hunnicutt, author. | Lewis, Michael S. (Michael Scott),
1977– author.
Title: Dialectical behavior therapy with adolescents : settings, treatments, and diagnoses /
K. Michelle Hunnicutt Hollenbaugh, Michael S. Lewis.
Description: New York, NY : Routledge, 2018. | Includes bibliographical references.
Identifiers: LCCN 2017036111 (print) | LCCN 2017036683 (ebook) | ISBN 9781315692425
(eBook) | ISBN 9781138906020 (hbk) | ISBN 9781138906037 (pbk) |
ISBN 9781315692425 (ebk)
Subjects: | MESH: Cognitive Therapy | Adolescent | Mental Disorders—therapy | Mental
Disorders—diagnosis
Classification: LCC RC489.C63 (ebook) | LCC RC489.C63 (print) | NLM WM 425.5.C6 |
DDC 616.89/1425—dc23
LC record available at https://lccn.loc.gov/2017036111
ISBN: 978-1-138-90602-0 (hbk)
ISBN: 978-1-138-90603-7 (pbk)
ISBN: 978-1-315-69242-5 (ebk)
Typeset in Frutiger
by Apex CoVantage, LLC
Visit the eResources: www.routledge.com/9781138906037
Contents
List of figures vii

List of tables ix
Contributors xi
1 Introduction and Overview 1

2 Treatment Delivery and Implementation 19

3 Treatment Team and Continuity of Care 29

K. Michelle Hunnicutt Hollenbaugh and Jacob M. Klein
4 Outpatient Settings 39
5 Family Counseling 53
6 Partial Hospital Programs and Settings 63

Garry S. Del Conte
7 DBT in Inpatient Settings 85

8 Working Within School Sites 97

Richard J. Ricard, Mary Alice Fernandez, Wannigar Ratanavivan,
Shanice N. Armstrong, Mehmet A. Karaman, and Eunice Lerma
9 Eating Disorders 109

10 Conduct Disorder, Probation, and Juvenile Detention Settings 123

11 Substance Use Disorders 137

v
Contents
12 Other Diagnoses for Consideration 149

13 Comorbid Diagnoses and Life-Threatening Behaviors 161

14 Summary and Conclusions 171

Handouts177
Index235
vi
Figures
1.1 Biosocial Theory 4

6.1 Model of a Dialectical Milieu 66
9.1 Biosocial Theory as Applied to Eating Disorders 111
10.1 Biosocial Theory as Applied to Conduct Disorder/Criminal Behavior 126
11.1 Clear Mind, Clean Mind, Addict Mind 138
13.1 Behavior Chain Analysis 164
vii
Tables
1.1 Definition of Terms in the Structure and Implementation of DBT 3

1.2 DBT Dialectical Dilemmas 7
2.1 Pros and Cons of Implementing Standard DBT vs. DBT Informed 20
3.1 Treatment Team Members and Roles 30
4.1 Traditional DBT Treatment Targets and Hierarchy 40
4.2 Sample Skills Training Schedule 47
5.1 Options for Implementing Family Counseling in DBT 54
5.2 Treatment Targets in DBT Family Interventions 55
5.3 Sample Format of Multifamily Skills Group (Six Weeks) 59
6.1 DBT Treatment Assumptions in an Adolescent Partial Hospitalization
Program69
6.2 Curriculum Template for a DBT Partial Hospital Program 70
6.3 Curriculum for Six-Week Parent Middle Path Skills 73
6.4 Hierarchy of DBT PHP Behavioral Targets by Role and Mode 75
6.5 Treatment Targets for a DBT PHP 77
6.6 Daybreak Treatment Center Staff Agreements 79
7.1 Treatment Targets for Inpatient DBT 89
7.2 Sample Skills Training Format for Inpatient DBT 92
8.1 Teen Talk: Treatment Team Members and Roles 101
8.2 DBT Treatment Targets in the Teen Talk Program 102
8.3 Overview of the Teen Talk Skills Group Sessions 103
9.1 Treatment Targets in DBT for Eating Disorders 113
9.2 Sample Skills Training Schedule for DBT-ED 117
10.1 DBT Treatment Targets and Hierarchy With Conduct Disorders
and in Juvenile Detention Settings 127
10.2 Sample Skills Training Schedule for DBT for Conduct/Behavioral
Problems132
11.1 Adapted Treatment Targets for Treating Clients With SUDs 142
11.2 Sample Skills Module Format 144
12.1 DBT Treatment Targets and Hierarchy for Anxiety Disorders 150
12.2 DBT Treatment Targets and Hierarchy for Depression 153
12.3 DBT Treatment Targets and Hierarchy for Bipolar Disorder 155
ix
Contributors
Shanice N. Armstrong, PhD is an assistant professor at Henderson State Univer-

sity. She has several years of counseling experience working with at-risk and margin-
alized youth populations. Her interests involve multiculturalism and strength-based
approaches in counseling, resilience, supervision, and counselor education.
Garry S. Del Conte, PsyD, ABPP is clinical director at Daybreak Treatment Center in
Germantown, Tennessee. He is a licensed psychologist and a Linehan Board-Certified
DBT Clinician. His clinical specialization is working with children, adolescents, and
families.
Mary Alice Fernandez, PhD, LPC-S, NCC is a retired assistant professor from Texas
A&M University, Corpus Christi.
K. Michelle Hunnicutt Hollenbaugh, PhD, LPC-S, is an associate professor in the

Department of Counseling and Educational Psychology at Texas A&M University, Cor-
pus Christi. She has several years of clinical experience in a variety of settings, and has
spent the majority of this time researching and providing Dialectical Behavior Therapy
(DBT). She is currently conducting several research studies on adaptations of DBT, and
continues to facilitate the implementation of DBT-based clinical services for the local
community.
Mehmet A. Karaman, PhD is an assistant professor at the Department of Counsel-

ing and Guidance at the University of Texas Rio Grande Valley. He has practiced in
psychiatric hospitals, community mental health agencies, school districts, and non-
profit organizations. His research interests include achievement motivation, instru-
ment development, cross-cultural studies, and counseling children and adolescents.
Jacob M. Klein, M.Ed., is a Licensed Professional Clinical Counselor in the state of

Ohio, currently working in private practice with a focus on gender therapy, and is a
Ph.D. candidate at The Ohio State University.
Eunice Lerma, PhD is an assistant professor at the Department of Counseling and

Guidance at the University of Texas Rio Grande Valley.
Michael S. Lewis, PhD, LPCC-S, is a clinical professor at Capital University, and

has extensive experience working with adolescents and young adults. He has also
spent time working in substance abuse treatment facilities and high school settings.
Michael specializes in wellness- and mindfulness-based innovative interventions. His
xi
Contributors
research interests include college counseling, counselor development, and behavioral

addictions.
Wannigar Ratanavivan, PhD, LPC, NCC is an adjunct graduate faculty member at

Texas A&M University, Corpus Christi.
Richard J. Ricard, PhD, LPC-S is assistant dean and professor of Counseling and
Educational Psychology at Texas A&M University, Corpus Christi. He is also the
founder and director of the Teen Talk program at the Student Success Center in Cor-
pus Christi, Texas. His research focuses on program evaluation and implementation of
evidence-based counseling interventions in schools.
xii
1
Introduction and Overview
Dialectical Behavior Therapy (DBT) is considered a ‘third wave’ Cognitive Behavioral

Therapy—which means it’s a type of CBT that also includes other interventions and
approaches (for example, dialectics and mindfulness). Marsha Linehan began devel-
oping this treatment several decades ago, and since then it has saved communi-
ties thousands of dollars by helping clients avoid inpatient hospitalizations and acute
mental health care (Linehan, 2015). This is accomplished by working with clients so
they are reinforced for using new skills to cope with and manage emotions, instead
of resorting to life-threatening behaviors such as self-injurious or impulsive behav-
iors. Originally, Linehan developed DBT for individuals (primarily women) diagnosed
with borderline personality disorder (BPD). However, since then, research on DBT
has expanded substantially. Researchers have used DBT in many different settings
for both adults and adolescents struggling with a variety of diagnoses (Fleischhaker
et al., 2011). This research includes but is not limited to: eating disorders (Salbach-
Andrae, Bohnekamp, Pfeiffer, Lehmkuhl, & Miller, 2008), bipolar disorder (Goldstein,
Axelson, Birmaher, & Brent, 2007), inpatient treatment (Katz, Cox, Gunasekara, &
Miller, 2004), residential settings (The Grove Street Adolescent Residence, 2004), and
schools (Ricard, Lerma, & Heard, 2013).
Currently, there aren’t many evidence-based treatments available that focus spe-
cifically on treating adolescents struggling with pervasive emotion dysregulation (the
inability to effectively manage emotions in most life situations). There are also a lot
of adolescents who do not respond well to traditional treatment methods—or they
may simply benefit from supplemental interventions in addition to the treatment they
are currently receiving. For these reasons, DBT is a great option for clinicians who are
working with adolescents.
WHY DBT IS DIFFERENT

When Linehan originally started working with clients with borderline personality dis-
order, she noticed the type of intervention she was using was not always effective.
When she used a behavioral, problem-solving approach, she found it was too focused
on change, and clients became resistant. When she used a more person-centered
approach, she found the focus was too much on validation, and clients were unable
1
to problem solve in order to make necessary changes. As a result, she developed

DBT as a new type of approach that provides flexibility to use both validation and
change in the context of the client’s current situation (Linehan & Wilks, 2015). DBT
also addresses several problem behaviors at the same time. Treatment targets (goals)
are addressed through several modes (types of treatment): including skills groups,
individual sessions, and family sessions. This increases the intensity of treatment, but
it also increases the adolescent’s success in learning and using skills while decreasing
problem behaviors.
HOW TO USE THIS BOOK

Our goal in writing this book is to share approachable material for you to use in your
practice. Hopefully you will find this information useful on its own; however we also
recommend reading the foundational texts by Linehan (1993’s Cognitive-Behavioral
Treatment of Borderline Personality Disorder) and Miller, Rathus, and Linehan (2007’s
Dialectical Behavior Therapy With Suicidal Adolescents). Though we will give basic
explanations of the foundational principles of DBT here, those texts go much more in
depth and will help you understand the material.
We organized this book for maximum utility. This introduction will give an
overview of DBT, including all of the basic principles, functions, and modes of
treatment. Chapter 2 will include specifics on implementing DBT in your setting,
decisions to consider when adapting DBT, and the importance of commitment
strategies. Additionally, it will explore multicultural considerations. Chapter 3 will
discuss how to develop a consultation team and describe DBT as a collaborative
approach to treatment. Then, Chapters 4 through 8 will discuss considerations for
implementation in specific settings (different levels of care, schools, and forensic
settings). Chapters 9 through 13 will discuss specific diagnoses, and adaptations
for adolescents struggling with eating disorders, conduct disorders, substance
use disorders, other diagnoses, and how to address comorbidity and non-suicidal
self-injury (NSSI) specifically. Finally, Chapter 14 will include a summary and con-
clusions. The text will include usable handouts based in DBT for each correspond-
ing chapter.
TERMINOLOGY
Counselors, social workers, psychologists, and other professionals alike will find this
text helpful, but for the sake of brevity we will use the term clinician to refer to any
professional working in these capacities. We will also use the term client when dis-
cussing the adolescents you will be treating, though we are aware that you may refer
to them as patients, students, etc. There are a lot of different terms used in DBT that
will be described in this chapter and the next chapter—refer to Table 1.1 for a basic
definition of all of these terms.
2
Table 1.1 Definition of Terms in the Structure and Implementation of DBT
Term Definition
Treatment Mode A treatment mode describes how DBT will be provided. This
includes skills groups, individual counseling, phone coaching, and
consultation team. You can decide which modes to implement
based on the needs of your settings and your clients.
Skills Module In DBT skills training with adolescents, there are five
psychoeducational skills modules: mindfulness, interpersonal
effectiveness, emotion regulation, distress tolerance, and
walking the middle path. These modules are usually taught via
psychoeducational skills groups.
Treatment Strategies There are several types of treatment strategies in DBT. The
strategies discussed in this book include dialectical, core
(validation and problem-solving), stylistic, case management, and
commitment. We believe these will be the most applicable to
readers; however there are more strategies discussed in depth in
Linehan’s (1993) original text.
Stages of Treatment There are four stages in DBT treatment. Stage one has received
the most attention, and is the most common, as this is when
skills groups take place.
Treatment Targets There are several hierarchical treatment targets that are
identified for each individual client. These include decreasing life-
threatening behaviors, decreasing therapy-interfering behaviors,
decreasing quality-of-life-interfering behaviors, and increasing
behavioral skills. These are addressed via the modes of treatment
and facilitated by the strategies employed by the clinician.
Treatment Functions Miller et al. (2007) stated that treatment targets cannot
be addressed unless the program as a whole addresses the
following treatment functions: improving motivation to change,
enhancing capabilities, ensuring skill generalization, structuring
the environment to support clients and clinicians, and improving
therapist motivations.
THE BIOSOCIAL THEORY OF EMOTION DYSREGULATION

Dialectical Behavior Therapy is based on the biosocial theory of emotion dysregula-
tion. Emotion dysregulation is “the inability, despite one’s best efforts, to change or
regulate emotional cues, experiences, actions, verbal responses, and/or nonverbal
expressions under normative conditions” (Koerner, 2012, p. 4). Basically, the bioso-
cial theory states that pervasive emotion dysregulation is the result of two interacting
phenomena—biological predisposition to emotional vulnerability and an invalidat-
ing environment (see Figure 1.1). Biological predisposition means the adolescent’s
brain is biologically different, and therefore he or she is more vulnerable to volatile
3
Figure 1.1 Biosocial Theory
emotions than others. These adolescents may experience emotions more frequently
and intensely, and they may have more difficulty managing those emotions. The inval-
idating environment is often experienced as emotional neglect or harm from parents
or other significant adults, siblings, and peers. They learn that their emotions are not
important, wrong, or they are simply ignored. As a result, these adolescents do not
learn effective methods of regulating emotions, and then they experience pervasive
emotion dysregulation. The interaction of these two variables can lead to behav-
iors with potential harmful consequences—including self-injury and suicide attempts
(Linehan, 1993). See Handout 1.1 for a handout that explains the biosocial theory to
adolescents and parents. Without intervention, pervasive emotion dysregulation can
develop into more severe disorders. By using DBT, clinicians (and parents) can stop
reinforcing the harmful, life-threatening behaviors that the adolescent is currently
using to manage his or her emotions, and instead teach him or her new and effective
ways to cope.
DIALECTICS
The term dialectic may be new to some readers. It means the synthesis of oppo-
sites—that two, seemingly opposite, ideas or phenomena can both be correct and
4
co-exist (Linehan, 1993, p. 30). DBT treatment is, in itself, dialectical as clinicians work
with clients to validate them in their current situation, while also helping them make
changes for the better. One of the most important underlying assumptions in DBT is
that the client is doing the best that he or she can, and he or she can also do better
(Linehan, 1993). This highlights the dialectical nature of DBT—two ideas that appear
to be contradictory are both correct. Clinicians can take a dialectical approach to
counseling by being flexible and viewing reality as something that is always changing,
and that all aspects of reality are interrelated. In session, clinicians are encouraged to
find balance (Linehan referred to this balance as being on a “teeter-totter” with the
client on one side, and the clinician on the other, 1993, p. 30) and to ask “what are
we leaving out?” When teaching dialectics to clients, it is important to emphasize the
use of the terms “both” or “and” as opposed to “either” and “or.” In fact, one of
the key concepts of DBT, the Wise Mind, is the dialectic between the emotional and
the reasonable minds (Linehan, 2015).
Initially, I (the first author of this book) found the concept of dialectics to be vague
and ill defined at times—but after spending time with it I think that ambiguity is in
itself a description of being dialectical. Nothing is set in stone; nothing is black or
white. Everyone perceives reality through his or her own lens and that is what makes
two sides of a situation equally correct. For individuals, it is correct for them to see the
situation in their own manner, based on their own experiences.
MODES OF TREATMENT
By now, you have probably discovered how complex DBT treatment is. In traditional
DBT, there are several modes of treatment—that is, different facets that make up
the complete course of treatment. Fortunately, there is a lot of research that shows
that not all modes of DBT treatment are necessary for positive treatment outcomes.
Instead, clinicians should focus on what will work best given the setting they work
in and the clients they are treating. However, if the program does not offer all of
the standard DBT modes, it does not meet the requirements to be considered full
DBT. Clinicians should disclose this readily to clients—Linehan and colleagues suggest
terming the program as DBT informed instead. The standard DBT modes include psy-
choeducational skills groups, individual sessions, intersession phone coaching, and a
clinician consultation team (Linehan, 2015).
Skills Groups
Psychoeducational skills groups are adapted to fit the needs of the setting and can be
altered for the needs of the adolescents. Traditionally, they last for two hours weekly.
The first hour consists of reviewing homework and diary cards and the second hour
consists of learning new materials. Mindfulness practice is conducted at the begin-
ning and the end of each session, to emphasize the importance of this skill, and
increase the adolescents’ ability to use this skill. Typically, groups are closed during
5
each module and then opened again at the beginning of a new one. This provides the
group a sense of cohesion and comfort necessary to build skills, and then adolescents
who have experience with the material can support and give tips to new members
(Rathus & Miller, 2015).
Each module includes homework sheets for each skill learned, in addition to keep-
ing track of the skills the adolescent used throughout the week on his or her diary
card. Diary cards are (like they sound) a journal that the client keeps and they can
be customized to fit the needs of your client. We have included several versions that
are different based on the setting and the diagnosis. They can include moods on any
given day, any skills they have previously learned, and any target behaviors the ado-
lescent is working to increase or decrease (Miller et al., 2007). See Handouts 1.2–1.5
for several diary card examples.
Parents and caregivers may also take part in skills groups training, as this helps
increase skills acquisition in different settings. Increasing the skills of the parents also
serves to decrease any invalidation the adolescent may be experiencing (Rathus &
Miller, 2015). Clinicians can initiate skills groups in many different ways, depending
on the setting in which they are working. We will discuss different options for imple-
mentation further in each specific chapter. A short description of each skills training
module, including the adolescent specific module, Walking the Middle Path, is below.
Mindfulness
The practice of mindfulness is considered a foundation of DBT—it is the first skill
taught, and is practiced in every session (often several times). Mindfulness is based
in Eastern traditions; however, mindfulness from a DBT perspective is not considered
meditation. Instead, it is considered a skill to increase awareness in the moment and
the ability to manage one’s emotions and thoughts. The premise of mindfulness for
adolescents is that they often struggle with racing thoughts, or have difficulty focus-
ing on one thing at a time. By being mindful, they become better at controlling their
thoughts instead of letting them be controlled by them (Linehan, 1993). Adolescents
who regularly practice mindfulness are more aware of what is going on in their body,
their mind, and are able to put it in context to any given situation. They become bet-
ter at using skills effectively in difficult situations. The basic mindfulness skills include
what (what you do when you practice mindfulness) skills: observe, describe, partici-
pate; and how (how you practice mindfulness) skills: one-mindfully, nonjudgmentally,
and effectively (Linehan, 2015).
Interpersonal Effectiveness
The focus of this module is relationships, which can be extremely important consider-
ing how often adolescents struggle with volatile relationships. The skills in this module
focus specifically on keeping one’s own self-respect in a relationship, respecting others,
getting needs met in an assertive fashion, and successfully evaluating and managing
healthy relationships. Skills in this module (as with most modules) are often formulated
6
in the form of acronyms, and include aspects of problem-solving related to interper-

sonal effectiveness, myths regarding relationships, self-esteem in relationships, and vul-
nerabilities that may affect how we interact in relationships (Linehan, 2015).
Distress Tolerance
The distress tolerance module includes skills related to coping with the current situa-
tion, especially when the adolescent cannot change it immediately. These could also be
referred to as crises, in which the adolescent is struggling to manage emotions effec-
tively and is more likely to engage in life-threatening behaviors. Distress tolerance skills
include problem-solving, for example, considering which action to take to cope with
the situation, as well as numerous acronyms regarding activities the client can engage
in to cope with the situation when he or she cannot “fix” it right away. My favorite DBT
skill, radical acceptance, is also included in the module, and involves the act of mentally
accepting reality, over and over, as needed to reduce suffering (Linehan, 2015).
Emotion Regulation
This module not only deals with effective ways to cope with emotions, it teaches
clients the biology of emotions, including primary and secondary emotions, and their
purpose. Clients also learn about myths involving emotions, and how to be aware of
emotions both physically and mentally. Skills in this module focus on helping clients
engage in healthy coping activities and not only increase personal awareness of their
emotions, but awareness of others’ emotions as well (Linehan, 2015).
Walking the Middle Path

This module focuses on adolescent-specific dialectical dilemmas (see Table 1.2). It
also helps adolescents learn the concept of dialectics and how it can be helpful to
approach situations dialectically. Clients can learn skills to validate themselves and
others, and regulate their emotions effectively without vacillating between behavioral
extremes. This module also includes a basic section on behavioral principles including
reinforcement, punishment, and shaping behaviors (Miller et al., 2007).
Table 1.2 DBT Dialectical Dilemmas
Common Dialectical Dilemmas Adolescent Specific Dialectical Dilemmas
Emotional Vulnerability vs. Self-Invalidation Excessive Leniency vs. Authoritarian Control

Active Passivity vs. Apparent Competence Normalizing Pathological Behaviors vs.
Pathologizing Normative Behaviors
Unrelenting Crises vs. Inhibited Experiencing Forcing Autonomy vs. Fostering Dependence
Source: Adapted by permission from Miller et al., 2007.
7
Intersession Skills Coaching

Another standard mode of DBT treatment is 24-hour skills coaching. This mode is
possibly the most intimidating for clinicians, and as result, they may not include it for
fear of being accosted by after-hours calls. However, Linehan has stated she believes
that clients should not have to be suicidal to receive extra attention from their ther-
apists (Linehan, 1993). By allowing clients to call the clinician in between sessions as
needed, specifically for skills coaching, the client is reinforced for using these skills.
There are several rules that go along with phone coaching in DBT. Foremost, the client
must call his or her therapist before he or she engages in a life-threatening behavior.
This prevents the reinforcement clients often receive for engaging in that behavior
(e.g., extra attention and love from parents and peers). Instead, the clinician rein-
forces the client for calling for phone coaching, and seeking help before life-threat-
ening behaviors occur.
If the client abuses the privilege to call for coaching (e.g., calls but is resistant to
coaching or insists on discussing other topics) the clinician addresses this extensively
in the next individual session. By using time in session to focus on this therapy-inter-
fering behavior, the clinician discourages the client from engaging in this behavior
in the future. Most DBT therapists report that although they may initially receive fre-
quent calls for skills coaching, as the client develops his or her own skills, these calls
diminish and eventually cease. Per Linehan and colleagues, most skills coaching calls
last about ten minutes.
When working with adolescents, clinicians make phone coaching available to par-
ents and family members as well. This helps family members increase their own skills,
reduce vacillating between behavioral extremes, and increase skills generalization for
the adolescent. Though this may seem overwhelming, this mode of treatment can
be adapted to fit the needs of the treatment team and setting. For example, instead
of the primary clinician always being available for calls, team members can alternate
this responsibility. Others limit the times that they are available for coaching (however
this can limit the reinforcement of skills use and be less effective than full availability).
Finally, if the setting is residential or inpatient, intersession coaching can be con-
ducted by other trained staff members (e.g., nurses or social workers) who have been
adequately trained (Linehan, 2015).
Individual Sessions
Individual counseling sessions are an important facet of standard DBT. Individual
meetings often consist of evaluating commitment to treatment as well as interven-
tions to manage therapy-interfering, life-threatening, and quality-of-life-interfering
behaviors. Although clients review diary cards and other homework assignments in
skills group, in individual sessions the clinician and the client discuss the diary card in
more detail, in the context of their agreed-upon treatment targets. They also might
conduct behavior chain analyses to decrease reinforcement of any problem behaviors.
8
It is also important for the clinician to engage the adolescent’s parents in family
counseling sessions. These sessions can be scheduled regularly, or on an as needed
basis. The clinician can also schedule to meet with the parents individually. Again,
the goal of these sessions is to help the adolescent learn and use new skills, enhance
his or her ability to learn new behaviors (and extinction of unwanted behaviors), and
maintain commitment to treatment (Miller et al., 2007).
Consultation Group
One of the most important facets of standard DBT is the clinician consultation
group. From the beginning, Linehan has said that clinicians treating clients with
emotional dysregulation and/or engaging in life-threatening behaviors need their
own support. This is especially true for clinicians working with adolescents. The
consultation group should consist of any clinicians engaged in the DBT program,
as well as any nurses, doctors, case managers, and other staff members involved.
Although it changes depending on the setting, the consultation team should be as
comprehensive as possible. If you are a clinician working in private practice, you may
find this treatment mode challenging—there may not be enough people in your
practice who are involved in DBT to create a consultation group. However, you can
also engage in consultation groups outside of your office. When I first started offer-
ing skills groups in a community mental health center, I attended a DBT consultation
team that consisted of clinicians in community mental health centers throughout
the city, as there were not enough clinicians in each individual center to create a
consultation group. Similarly, I have known other clinicians in private practice who
emailed other DBT teams in the community and asked to join their consultation
team, or even joined a consultation team that met via online video conferencing.
Team meetings usually include case consultation with a focus on maintaining the
fidelity of DBT treatment. Consultation groups often meet weekly but this can vary
based on need. Meetings are set up a lot like DBT psychoeducational skills groups—
they usually include mindfulness, DBT-related activities and skills, and behavioral inter-
ventions for “consultation”-interfering behaviors (e.g., repeated tardiness or lack of
preparation) (Linehan, 1993).
Ancillary Modes
In addition to the standard modes of treatment, there are several other modes that
may or may not be included in DBT treatment—for example, case management and
pharmacotherapy. These modes should complement DBT treatment though they may
not always be DBT based (e.g., treatment is provided from a provider that does not
adhere to DBT principles). However, at the very least, clinicians should be able to work
with other treatment providers to ensure they are on the same page with regard to
reinforcing (or not reinforcing) behaviors the client and family use to manage emotion
dysregulation (Linehan, 1993).
9
TREATMENT STRATEGIES
Treatment strategies in DBT encompass any approaches or techniques the clinician
uses to achieve treatment goals. These techniques include commitment strategies,
dialectical strategies, validation strategies, problem-solving strategies, stylistic strate-
gies, and case management strategies. A brief overview is provided here; however if
you are interested in learning about these in more detail, I highly encourage you to
read about them in Linehan’s (1993) text Cognitive-Behavioral Treatment of Border-
line Personality Disorder.
Orientation and Commitment Strategies

Orientation and commitment strategies are essential to help the client understand
the process of DBT, the expectations for both the client and clinician, and finally to
engage the client in a commitment to certain parameters (length and frequency) of
treatment. The importance of orienting and committing the client to treatment can-
not be understated. In fact, I believe that most of the problems I have experienced
with treatment compliance in DBT were related to the fact that I did not engage in
enough orientation and commitment to treatment in the beginning, or I did not
revert back to commitment strategies when they were needed mid-treatment. These
strategies will be discussed fully in Chapter 2.
Dialectical Strategies
In both adolescent and adult DBT, dialectical strategies include three aspects: bal-
ancing treatment strategies, teaching dialectical behaviors to the client, and spe-
cific dialectical strategies. Balancing treatment strategies is one of the core themes
throughout DBT treatment—and it involves constantly balancing acceptance and
change. As Linehan stated “The primary therapy dialectic is that of change in the
context of acceptance of reality as it is” (1993, p. 201). By focusing on validation and
change, the clinician is able to provide support as needed while also helping the client
to work towards change.
Teaching dialectical behaviors to the client is also important because it can help
the adolescent see where he or she (or his or her family) is maintaining an either/
or stance in any given situation. By learning about dialectics, clients can take on a
dialectical worldview in their current life, which will increase their ability to be flexible
and understand the viewpoint of others. Again, it should be noted that by teaching
dialectical strategies you are not invalidating either side of the polarities that may
arise for your client—instead, you are validating both (Miller et al., 2007).
Finally, there are several specific dialectical strategies that DBT clinicians employ to
attain treatment goals with adolescents and their families. These include: entering
the paradox, using metaphors, playing devil’s advocate, extending, activating wise
mind, making lemonade out of lemons, allowing natural change, and conducting a
dialectical assessment. To learn more about these strategies in detail, refer back to the
Linehan (1993) text or Miller et al. (2007).
10
Validation and Problem-Solving Strategies

Validation and problem-solving are considered core strategies in DBT, which means
they are present in all interactions between the clinician and the client. As Miller et al.
(2007) noted, when a clinician feels “stuck” with a client in treatment, often it is
because he or she is focusing too much on either validation or change (problem-solv-
ing). Therefore, it is always important to utilize both, often simultaneously.
In DBT, validation strategies have six different levels, and four different types. This
probably seems complex and overwhelming to simply read about, much less try to
implement! However, you will likely find that you are engaging in the majority of
these strategies already, especially since many of them have a foundation in per-
son-centered therapy. For example, using basic reflections of feelings and thoughts,
and providing encouragement, praise, and reassurance are all activities most clini-
cians use in all counseling sessions, DBT or otherwise.
Problem-solving strategies involve two steps—first the clinician and the client must
fully understand the problem at hand, and second, they work together to address the
problem and generate solutions. This is best done using a Behavior Chain Analysis
(BCA) and can be conducted in a variety of formats. See Handout 1.6 for a BCA work-
sheet we created that may be helpful specifically for working with adolescents. There
are several steps included in creating a BCA. First, define the problem—whether it is a
life-threatening behavior, quality-of-life-interfering behavior, or a therapy-interfering
behavior. Then identify the vulnerabilities the client may have that would pre-dispose
him or her to engaging in the behavior, and lastly, the consequences of the problem
behavior. The client then will work (with the help of the clinician) to identify the
thoughts, feelings, and behaviors that led to the problem behavior. Finally, they work
to identify a new chain with different behaviors, thoughts, and feelings that will lead
to a new, more acceptable behavior. I teach my clients to be aware of the alphabet
in this regard. For example, “A” always comes before “B,” “M” before “N,” and so
on. If the problem behavior is “Z,” we must identify the behaviors and thoughts that
represent A–Y. If they can avoid preceding behaviors and thoughts, they are much
more likely to avoid the problem behavior altogether. Remember, problem-solving
strategies go hand in hand with validation strategies, and therefore when engaging
in problem-solving, it is important for the clinician to engage in validation through-
out. In other words, continue to approach treatment dialectically.
Stylistic Strategies
Stylistic strategies speak less to the what a clinician is going to do, and more to the
how he or she will engage the client in treatment (Miller et al., 2007). There are two
stylistic strategies—reciprocal strategies and irreverent strategies. Reciprocal strate-
gies include being genuine and open to what the client is saying, and also at times
using self-involving statements (e.g., expression of personal feelings regarding the
client in the moment). This could also be considered using immediacy in session. For
example, the clinician may make comments on his or her own feelings in session
11
or on the client’s thoughts, feelings, and behaviors related to the counseling pro-
cess (Linehan, 1993). Irreverent strategies can be especially helpful with adolescents,
and can include using humor, a different vocal tone, or some well-placed sarcasm.
Though you will obviously want to be careful when using this skill, the main idea is
that by using this strategy you will change the effect of the conversation or get the
client’s attention by putting him or her off balance, so to speak. This will help take
the client out of his or her normal behavioral patterns that maintain emotion dysreg-
ulation, and helps him or her stop and use skills to effectively manage emotions. One
example of this might be if a client reports a desire to sneak out of the house that
evening to use drugs with his or her friends, and the clinician responds (in a light,
non-accusatory tone, perhaps with a smile) “you’re right, that’s an excellent idea. I’m
sure your parents won’t mind that at all.” Reciprocal strategies (as with most things
in DBT) should be balanced with irreverent strategies (Miller et al., 2007).
Case Management Strategies

A clinician may incorporate case management strategies when there are issues with
the client’s environment that are preventing his or her ability to be successful in treat-
ment. The foremost strategy in this section is called therapist-to-patient consulta-
tion. The main goal of this is for the clinician to help the client solve his or her own
problems, instead of intervening on his or her behalf. By doing this, the clinician
can help the client build mastery of his or her skills, while also minimizing splitting
that sometimes happens with professionals and clients (when a client consciously or
unconsciously divides counselors and staff against each other). The other strategies in
this section including environmental interventions (considered as a last resort, when
potential harm could come to the client and he or she does not have the skills or
resources to solve the problem at hand) and consultation team meetings, where the
consultation team actually applies DBT strategies and interventions to the clinician,
when needed (for example, which the clinician’s commitment is wavering, or he or
she is engaging in therapy-interfering behaviors) (Linehan, 1993).
STAGES OF TREATMENT
There are four stages in DBT treatment. Each of these stages has specific treatment
targets. Though the stages are numbered based on symptom severity from one to
four, the client may not move through the stages linearly and may even meet criteria
for two stages at the same time. When a client is initially admitted to treatment, the
clinician, along with the consultation team, will make a decision regarding which
stage fits the client’s needs for the best treatment outcomes (Linehan, 1993).
Pretreatment Stage
Commitment strategies are essential during the pretreatment phase (see Chapter 2).
The length of the pretreatment phase varies, depending on the setting and diagnosis.
12
The goal of pretreatment is for the clinician and the client to reach mutually agreed-
upon expectations and a commitment to treatment. As we are sure you know, pre-
mature termination in counseling is common, especially for adolescents struggling
with labile emotions. By taking the time needed to commit the client to treatment,
hopefully you can avoid attrition. If at all possible the client should be given the
choice between DBT and another form of treatment, as this will also increase his or
her commitment. The pretreatment tasks in DBT with adolescents include: 1) Inform
and orient the client and the family to DBT, 2) Secure the adolescent and the family’s
commitment to treatment, and 3) Secure the therapist’s commitment to treatment
(Miller et al., 2007).
Stage One
This stage is by far the most studied stage of DBT treatment. In this stage, the
treatment targets are (in order of importance): decreasing life-threatening behav-
iors, decreasing therapy-interfering behaviors, decreasing quality-of-life-interfering
behaviors, and increasing behavioral skills. Psychoeducational skills groups are usually
implemented during stage one to address these treatment targets. The client can
spend up to a year in this stage, as Linehan posits that clients should complete all
skills training modules twice, to ensure mastery (1993). However, this model may be
adjusted based on the needs of the client and the setting (Rathus & Miller, 2015).
Although clients usually begin in this stage, and then move on to other stages, if they
experience a relapse into previous life-threatening or therapy-interfering behaviors,
they may move back a stage in order to refresh these skills. Clients remain in stage
one until they are no longer engaging in life-threatening behaviors.
Stage Two
The major treatment target of stage two is decreasing post-traumatic stress. A client
can either begin treatment in stage two (if he or she has previously learned to man-
age the aforementioned behaviors), or he or she can move on to stage two after
successfully completing stage one. As Linehan (1993) warns, the client’s ability to
cope with the current situation, or with post-traumatic stress responses, should not
be mistaken as a time to end treatment. Terminating treatment too early may lead
to a relapse in stage one problematic behaviors. Instead, adolescents should engage
in individual counseling (along with, possibly, a stage one graduate support group)
and focus on accepting the facts of their trauma; reducing stigmatization, self-inval-
idation, and self-blame; reducing denial and intrusive stress-response patterns; and
reducing dichotomous thinking about the traumatic situation (Linehan, 1993).
Stage Three
In this stage, the client works on individual goals and increasing self-respect. As Line-
han noted, once clients are at this stage in treatment, they are likely to be struggling
with self-blame and self-hatred that limit their ability to achieve happiness. This stage
13
is centered on helping the client conceptualize his or her past, and process this with
others. However, at this stage, though the client has moved past some of the life
threatening, therapy-interfering, and quality-of-life-interfering behaviors of the previ-
ous stages, he or she may experience a relapse in life-threatening or quality-of-life-in-
terfering behaviors. If this happens, the clinician should avoid shaming the client and
instead focus on helping the client engage in more learning and previous coping skills
(Linehan, 1993).
Stage Four
In stage four, the client focuses on resolving a sense of incompleteness, and finding
freedom and joy. Essentially, in this stage the client works toward self-actualization,
and may be more spiritually based, in which the client explores meaning and pur-
pose. It is important to note that there is not much published on stage four in the
DBT literature, likely due to the fact the clients with most urgent needs are in stage
one.
STAGE ONE TREATMENT TARGETS

As stage one is the most common, we will spend some time describing the treat-
ment targets in this stage. Once you have identified that your client meets criteria
for stage one treatment, you will need to identify all of his or her reported problem
behaviors. Then, you will need to decide which category the behavior falls under—
life threatening, therapy interfering, or quality of life interfering. This is a judgment
call that you will make on an individual basis—and this is one of the reasons the
consultation group is so important! Remember that Linehan and colleagues con-
sider life-threatening behaviors any behavior that puts the individual or others in
imminent harm—other behaviors that may lead to negative consequences (e.g.,
risky sexual behavior) are more likely to be considered quality-of-life-threatening
behaviors.
Decreasing Life-Threatening Behaviors

Many adolescents, regardless of their diagnosis, struggle with pervasive emotion
dysregulation, and in an attempt to manage their emotions, they may engage in
life-threatening behaviors. Even if they are ultimately ineffective at assuaging their
feelings long-term, these behaviors act as an immediate relief to an otherwise tumul-
tuous situation. This usually is experienced through non-suicidal self-injury, but can
also include suicide threats/attempts, thoughts or threats of harming others, or failing
to take life-sustaining medications. Life-threatening behaviors are addressed in stage
one via skills training, individual treatment, intersession phone coaching, and the
clinician consultation team (Linehan, 2015). See more on addressing life-threatening
behaviors in Chapter 11.
14
Decreasing Therapy-Interfering Behaviors

Not surprisingly, there are a lot of actions under this umbrella. These activities can
be any behavior engaged in by the client, the clinician, and/or family members that
can limit the effectiveness of treatment. Therapy-interfering behaviors are further
organized by activities that interfere with receiving therapy, with other clients, and/or
burn out the counselor. The skills trainer and/or individual clinician can address these
behaviors as needed.
Behaviors That Interfere With Receiving Therapy

There are numerous actions that can prevent the client from properly receiving ther-
apeutic interventions from the clinician. These behaviors may include circumstances
that prevent the client from attending therapy (e.g., tardiness, cancellations, repeated
hospitalizations), inattentiveness in therapy (e.g., drug or alcohol use, disruptiveness
in group sessions, emotional outbursts), non-collaboration (e.g., not responding,
responding repeatedly with “I don’t know”), combativeness (e.g., lying/arguing/chal-
lenging), and lastly, noncompliance (e.g., not completing homework or diary cards,
not participating) (Miller et al., 2007).
Behaviors That Interfere With Other Clients

Adolescents interact with each other frequently during the psychoeducational skills
group. These interactions are often extremely beneficial, as they can learn from one
another and model appropriate responses and behaviors. However, some adolescents
may engage in behaviors that interfere with others’ success in treatment. Examples of
these activities include engaging other clients in destructive behaviors, being openly
judgmental of others (or the DBT process), or being loud and disruptive to other cli-
ents outside of session. Adolescents can be susceptible to peer pressure, which can
increase the likelihood of these behaviors (Rathus & Miller, 2015).
Behaviors That Burnout the Clinician

As aforementioned, clinicians engaging in DBT need support, and the intensity of the
treatment can have a negative impact on the clinician. Clients may contribute to this
by challenging the clinician’s limits and boundaries, being aggressive, or interfering
with the motivation of other staff members through similar behaviors (Linehan, 1993).
Family Therapy-Interfering Behaviors

Family members can be a significant influence on the success of DBT treatment for
adolescents. Similarly, family members can derail treatment by engaging in interfering
behaviors. Examples may include not providing transportation for the client, or not
allowing the adolescent to use the phone to engage in phone coaching. The clinician
15
will often address these behaviors with the client, and facilitate the client’s ability
to use his or her skills to communicate his or her needs is the situation while also
respecting relationships (Miller et al., 2007).
Clinician Interfering Behaviors

Lastly, the clinician may unwittingly disrupt the therapeutic process. He or she can
become too non-dialectical (e.g., pushing too hard for change, or being overly vali-
dating without focusing enough on change) or being disrespectful to the client (e.g.,
being condescending, approaching a situation emotionally). The clinician can limit
these behaviors by engaging in the consultation team, and being open to feedback
from clinicians and clients regarding these behaviors (Linehan, 1993).
Decreasing Quality-of-Life-Interfering Behaviors

Due to the fact that their brains (specifically, frontal lobes) are still developing, all
adolescents struggle with impulsivity and poor decision-making. When this stage of
development is combined with pervasive emotion dysregulation, the list of activi-
ties that they may engage in that negatively impact quality of life are innumerable.
These behaviors may include impulsivity, drug use, promiscuous sexual behavior, and
engaging in abusive relationships. It may be difficult for adolescents and parents to
discern which behaviors and activities may be considered normative. Regardless, you
may spend time in consultation with the client, the family, and other clinicians on the
team to determine what the agreed-on treatment targets will be during this stage.
Quality-of-life-interfering behaviors are typically addressed after therapy-interfering
behaviors. Linehan posited that if therapy is unproductive, the clinician and the client
would be unable to address the quality-of-life-interfering behaviors as well.
Increasing Behavioral Skills

Finally, one of the most important facets of stage one is helping clients develop skills
to combat previous dysfunctional coping strategies. This is where the weekly skills
group (or learning skills in individual therapy) is important to incorporate interpersonal
effectiveness, emotion regulation, mindfulness, and distress tolerance. Behavioral
skills replace the previous problem behaviors, and help the client effectively manage
his or her emotions. Clients learn these skills through weekly homework assignments,
and keep track of when/how they use them via diary cards (Rathus & Miller, 2015).
STAGE ONE SECONDARY TREATMENT TARGETS—

DIALECTICAL DILEMMAS
Referring back to Table 1.2, Linehan noted that clients struggling with emotion dys-
regulation often fall into behavioral patterns that vacillate between two extremes,
16
which she calls dialectical dilemmas. Basically, the problem behaviors you identified
as primary treatment targets (above) become patterns, based on the client under-reg-
ulating or over-regulating their emotions (Miller et al., 2007). As result, the goal is
to even out emotion regulation and bring the client back to the synthesis of both
polarities.
Emotional Vulnerability vs. Self-Invalidation: The client will either experience

extreme emotions with little or no effort to effectively manage them, or com-
pletely invalidate his or her emotions.
Active Passivity vs. Apparent Competence: The client will vacillate between doing
little to help him or herself (and looking to others for help), or will seem like he
or she has the skills and ability to manage a situation, when in reality, he or she
does not.
Unrelenting Crises vs. Inhibited Experiencing: In this dilemma, the client vacillates
between constant emotional crises (in an attempt to cope with emotions) and
avoiding situations that trigger any difficult emotions.
In addition to the behavioral patterns delineated by Linehan (1993), Miller et al.

(2007) noted that there were several dialectical dilemmas they noticed that occurred
among parents, adolescents, and therapists. Not only do the adolescents fall into
these behavioral patterns, but parents and therapists do as well, often in reaction to
the adolescents’ extreme vacillations.
Excessive Leniency vs. Authoritarian Control: This refers the vacillation between
either letting the adolescent do as he or she pleases at any given time, or impos-
ing extreme discipline and punishments.
Normalizing Pathological Behaviors vs. Pathologizing Normative Behaviors: The
parents (or adolescent) either think that extreme, harmful behaviors are nor-
mal, or think and treat normal adolescent behaviors as extremely dangerous or
abnormal.
Forcing Autonomy vs. Fostering Dependence: Parents or adolescents vacillate
between cutting off ties, with the expectation of the adolescent to be self-suffi-
cient too quickly, and the adolescent not having any freedom or autonomy at all.
Why should we care about these dialectical dilemmas? These patterns can actually
perpetuate related problem behaviors. It is also worth noting that in several adapta-
tions of DBT, researchers have added dialectical dilemmas specific to the population
they are treating, so keep an eye out for that in the other chapters.
CONCLUSION
This chapter reviewed the biosocial theory of emotion dysregulation, treatment modes
and targets, stages of DBT treatment, and various treatment strategies. If you are
17
feeling overwhelmed, no worries—I have found that once I became familiar with the
material (and with the help of the DBT consultation team), this information became
second nature, and easily flowed with the implementation of skills and strategies in
group and individual sessions. I think you will also find this material easy to approach
once you have had time to digest and begin to apply it.
REFERENCES
Fleischhaker, C., Böhme, R., Sixt, B., Brück, C., Schneider, C., & Schulz, E. (2011). Dialectical
behavioral therapy for adolescents (DBT-A): A clinical trial for patients with suicidal and
self-injurious behavior and borderline symptoms with a one-year follow-up. Child and Ado-
lescent Psychiatry and Mental Health, 5(1), 1–10. doi:10.1186/1753-2000-5-3
Goldstein, T. R., Axelson, D. A., Birmaher, B., & Brent, D. A. (2007). Dialectical behavior therapy
for adolescents with bipolar disorder: A 1-year open trial. Journal of the American Academy
of Child & Adolescent Psychiatry, 46(7), 820–830. doi:10.1097/chi.0b013e31805c1613
Katz, L. Y., Cox, B. J., Gunasekara, S., & Miller, A. L. (2004). Feasibility of dialectical behavior
therapy for suicidal adolescent inpatients. Journal of the American Academy of Child &
Adolescent Psychiatry, 43(3), 276–282.
Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. New York, NY: Guil-
ford Press.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder.
New York, NY: Guilford Press.
Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). New York, NY: Guilford Press.
Linehan, M. M. & Wilks, C. R. (2015). The course and evolution of dialectical behavior therapy.
American Journal of Psychotherapy, 69(2), 97–110.
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal
adolescents. New York, NY: Guilford Press.
Rathus, J. H. & Miller, A. L. (2015). DBT® skills manual for adolescents. New York, NY: Guilford
Press.
Ricard, R. J., Lerma, E., Heard, C. C. (2013). Piloting a Dialectical Behavioral Therapy (DBT)
infused skills group in a Disciplinary Alternative Education Program (DAEP). Journal For
Specialists in Group Work, 38(4), 285–306.
Salbach-Andrae, H., Bohnekamp, I., Pfeiffer, E., Lehmkuhl, U., & Miller, A. L. (2008). Dialectical
behavior therapy of anorexia and bulimia nervosa among adolescents: A case series. Cogni-
tive and Behavioral Practice, 15(4), 415–425. doi:10.1016/j.cbpra.2008.04.001
The Grove Street Adolescent Residence of the Bridge of Central Massachusetts, Inc. (2004).
Using dialectical behavior therapy to help troubled adolescents return safely to their
families and communities. Psychiatric Services, 55(10), 1168–1170. doi:10.1176/appi.
ps.55.10.1168
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2
Treatment Delivery and Implementation
This chapter will explore key components of treatment delivery in DBT. This includes
committing the client to treatment, considerations for implementing your DBT pro-
gram, and assessment. We will also explore the pros and cons of using standard DBT
as opposed to an adapted form of DBT (DBT informed). Additionally, multicultural
considerations will be discussed.
IMPLEMENTATION
Standard DBT vs. DBT Informed

As mentioned in the previous chapter, standard DBT is an intensive treatment with
multiple modes of treatment to address all treatment targets. These modes include
individual therapy, group skills training, between-session skills coaching, and the clini-
cian consultation team (details on these are provided in Chapter 1). In DBT informed,
only some modes of DBT are implemented, or adaptations are made to the original
DBT model.
There are pros and cons on both sides of implementing standard DBT and DBT
informed treatment. The benefits of implementing standard DBT are that this method
of treatment is the most intensive, and has the most research behind it. Each mode
addresses specific treatment functions and it is a highly structured intervention. There
are clear expectations for the clinician and client alike. Conversely, the cons of imple-
menting standard DBT are that it is very time intensive, and because there are so
many modes of treatment, it may be costly for clients and insurance companies may
be unwilling to reimburse for all services.
Similarly, there are pros and cons to implementing DBT informed treatment. The
pros are that the treatment is tailored to the needs of the setting—that can include
tailoring the time frame of the treatment, only implementing some modes of treat-
ment, or adapting the material to fit specific needs and populations. There is research
available on DBT informed approaches (albeit, not as much as with standard DBT),
with promising preliminary results and positive outcomes for certain populations,
including adolescents. The cons of DBT informed implementations are that they may
include less structure, there are fewer resources available for specific populations, and
19
Table 2.1 Pros and Cons of Implementing Standard DBT vs. DBT Informed
Pros of Standard DBT Pros of DBT Informed
Standardized implementation clarifies The skills are adaptable for

expectations for all stakeholders several different populations and
settings
Evidence-based treatment can increase There is research that supports the
ability to attain funding effectiveness of using only some modes
of DBT
Each mode of DBT addresses specific Can be more cost effective
treatment targets
Standard DBT has the most research Increases flexibility of the treatment
supporting its effectiveness
Cons of Standard DBT Cons of DBT Informed
Implementing all modes can be costly, Research is limited on effectiveness
as well as training all clinicians and staff
involved in the treatment
Standard DBT requires full commitment Difficulty in structuring the treatment,
by practitioners fewer resources available
less research base for adapted interventions (Hunnicutt Hollenbaugh, Klein, & Lewis,
2015). See Table 2.1.
Training
Training is a major consideration with implementing DBT in your setting. The gold
standard in DBT training is the ten-week, intensive training offered by Behav-
ioral Tech. This training is only offered to DBT teams, and, in my opinion, is fairly
expensive ($10,000 for teams up to four, prices increase from there). However,
as noted in the title, it is intensive and provides a lot of feedback and guidance
for teams working to set up their DBT program. There are several other training
options in addition to this—Behavioral Tech (www.behavioraltech.org) also pro-
vides an advanced, intensive training for individual clinicians, and trainings for
specific applications of the treatment. Most recently, the procedures for becoming
a Certified DBT Therapist have been put in place by Linehan and colleagues, and
it is a lengthy process, including passing an exam and engaging in case consulta-
tion. Per the certification website (www.dbt-lbc.org), it costs a total of $845 from
start to finish, with a $95 yearly recertification fee. However, certification is not
required for you to use DBT in your practice and is only one of many options you
have for training.
20
Different Settings
Implementing DBT in different settings can require adaptations based on the needs
of your clients and the setting. These changes may include which modes you employ,
and who is involved in your treatment team. Miller, Rathus, & Linehan (2007) wrote
that at a bare minimum, you should have two clinicians involved in the treatment
team when working with adolescents. This will allow adequate support for co-lead-
ing groups and engaging in consultation. Other professionals can (and ideally should)
be involved as well—for example, psychiatrists, nurses, and school counselors, just
to name a few. The hope is that all members of the team will have some training in
DBT, be familiar with the underlying principles, and grasp their particular role in the
treatment.
It is also important to consider what modes will be provided, how treatment
targets will be addressed, and how the overall program will adhere to the various
treatment functions. Skills group is the most common mode and the most easily
provided. However, it may be difficult to address all treatment targets in the psy-
choeducational skills group, which is why you may want to consider including other
modes, including individual sessions. The intersession skills coaching may not be
possible in some settings; however, by being creative, you can still achieve the treat-
ment goals—some programs are designed so clients can seek coaching from other
professionals (e.g., technicians, nurses) between group and individual sessions to
help generalize skill use.
Structural/Financial Considerations
Obviously, standard DBT can be expensive, and, as mentioned, insurance may not
necessarily cover all modes. For example, clinicians have reported difficulties getting
reimbursed for between session skills coaching in addition to weekly individual and
group sessions. From a financial perspective, it simply may not be feasible for every
organization to provide all modes of DBT treatment. An additional concern for many
clinicians is physical space. It may not be structurally reasonable to implement full
DBT in an inpatient or intensive outpatient unit. In schools, you may only be able to
offer DBT in a group format. It is also important to consider how you will implement
DBT into the existing infrastructure—will you only offer DBT, or will it be one of many
treatment interventions you provide? In depth discussions with administrators and
stakeholders in the planning stages can help streamline the implementation process
and reduce any problems that may come up in the future.
Different Populations
As you likely have noticed, there are several chapters in this text that address the use
of DBT with different populations. This is due to the fact there are several populations
that struggle with emotion dysregulation, and could therefore benefit from a DBT
approach. Since DBT is a flexible treatment, you can easily adapt DBT interventions
21
to the needs of the population you are treating. Adaptations can be made to the
material, how it is presented, and how much is presented at one time. Just as the
original DBT material has been adapted for adolescents, clinicians should engage in
thoughtful consideration regarding which adaptations will be appropriate, while also
being mindful of maintaining the fidelity of the treatment.
COMMITMENT STRATEGIES
There are several commitment strategies DBT clinicians use to engage the client in
treatment. As we mentioned before, spending time committing the client to treat-
ment is essential and can predict overall success in treatment. If you begin treatment,
but do not have at least partial commitment to treatment, you may be engaging in
a therapy-interfering behavior yourself! At best, lack of commitment can reduce the
effectiveness of the treatment and at worst, lead to premature termination. Though
these strategies are especially important in the beginning, you may need to default
back to these strategies throughout the treatment, essentially recommitting the cli-
ent to treatment. Commitment strategies in DBT include: foot in the door/door in
the face, playing the devil’s advocate, evaluating pros and cons, connecting present
commitments to prior commitments, highlighting freedom to choose and absence of
alternatives, and cheerleading (Miller et al., 2007). See Handout 2.1 for a handout
that will help you remember the DBT commitment strategies.
Foot in the Door/Door in the Face

You may be familiar with these terms, and you may have even used them in other
treatment approaches. With foot in the door, the clinician asks for an initial small
commitment from the client—hence, the clinician is getting his or her foot in the
door. Then, once the client has agreed to make this small commitment, the clinician
requests a larger commitment. With the door in the face technique, the clinician
makes a very large or seemingly impossible request, and then, when the client balks
at the idea, the clinician reduces this request significantly. In my experience, although
both techniques have worked effectively, I have found door in the face to be more
effective with adolescents, as they are usually resistant to agreeing to small requests
at first, but are more likely to agree after comparing it to something much larger. For
example, you could start by asking the client to complete a full diary card, but then
reduce it to just a small portion of the diary card.
Playing Devil’s Advocate

I have to admit, when I first heard about this technique, I was skeptical. Again, as
it sounds, the clinician takes the opposite side of what he or she might normally
take in the counseling relationship. This throws off the balance (remember the met-
aphor Linehan uses—the client and clinician are on either sides of a teeter-totter) the
22
adolescent is familiar with and can lead him or her to switch sides with you com-
pletely. So, instead of arguing for full commitment to treatment, you might instead
suggest the client isn’t ready for this, or it isn’t a good idea. Sounds crazy, right? Once
I was working to engage an adolescent in treatment, and she was giving reason after
reason as to why she couldn’t do the work, couldn’t use her skills, and basically was
a hopeless case. Finally, admittedly, with a little frustration, I stated “Maybe you’re
right. Obviously this isn’t working, and it sounds like you’ve tried everything.” The cli-
ent blinked, and stopped for a second. Then she said “But I can’t give up.” I couldn’t
believe it! It worked! We then engaged in a discussion about that piece of her that
didn’t believe she should give up. She then started convincing me why she needed
to keep trying.
Evaluating Pros and Cons

The main objective of this technique is to evaluate the pros and cons of engaging in
DBT treatment with the client in a realistic and nonjudgmental manner. Not only does
this highlight the fact that there will be cons (e.g., homework, time commitment),
it is also an opportunity to emphasize the benefits (e.g., building a life worth living).
Your job will be to find a way to emphasize the fact the pros outweigh the cons. This
not only helps the client view the situation objectively, it will help him or her consider
possible obstacles that may come up later in treatment.
Connecting Present Commitments to Prior Commitments

There are times when your client will need to be reminded of the previous com-
mitment he or she made in order to reinforce a current commitment. Connecting
current commitments to prior commitments is a strategy that is especially important
in recommitment. One of the major examples used in DBT is when a client begins to
threaten to use behaviors that he or she had committed not to use when treatment
began. For example, if your client committed to not using alcohol, but then, after a
fight with his mother, states he plans to go out that night and drink, you could ask (in
a nonjudgmental tone) “But I thought you were going to try your best not to do that?
That was what you committed to when we started treatment” (Miller et al., 2007, p.
147). This technique helps reaffirm the client’s positive choices while also reminding
him of his obligations in the treatment process.
Highlighting Freedom to Choose and Absence of Alternatives

This technique can seem a little manipulative (though really, to an extent, these are all
a little manipulative). Highlighting the freedom to choose and absence of alternatives
involves pointing out the fact that the client has a choice whether to stay in treat-
ment, however the choices are highly stacked towards staying. Basically, on one side,
the option is to try to manage things as he or she had been previously (which was
unsuccessful) or, he or she could try the DBT program, which could ultimately lead to
23
a life that includes all of the things that are important to the client. When presented
that way, the client sees that leaving treatment is not really a viable option, but this
provides the control to make that decision independently.
Cheerleading
As we’ve said, in DBT, the clinician is constantly vacillating between acceptance
and change. Cheerleading is the acceptance piece of the commitment strategies.
Throughout treatment, it is important to praise your clients and emphasize your belief
that they can be successful in this treatment. With every commitment strategy used,
a validating, cheerleading statement can help increase the client’s commitment. This
highlights two of the dialectical assumptions in DBT—the client is doing the best he
or she can, and, he or she can do better, and try harder.
ASSESSMENT
There are several aspects of assessment in DBT: initial diagnostic assessment of the
client, valuation of treatment outcomes, and overall appraisal of the program.
Initial Diagnostic Assessment

You likely already have procedures for conducting an initial biopsychosocial assess-
ment that helps you gather ample information regarding symptoms, history of the
presenting problem, and any other contributing factors. However, you may wish to
add some questions specifically related to DBT treatment targets such as life-threat-
ening behaviors, therapy-interfering behaviors, and quality-of-life-interfering behav-
iors (see Chapter 1 for more detailed descriptions). These treatment targets are a
major facet of DBT treatment planning; therefore it is important to attain a full picture
of what these behaviors look like during the assessment period. You will also want to
include aspects to assess the fit of the program for the client. This can include time
commitment, program inclusion criteria (to be discussed later in this chapter), and
adolescent/parent willingness to commit to the program (Miller et al., 2007).
Assessment of Treatment Outcomes

The treatment targets in your program may be the same as traditional DBT programs
(e.g., increase emotion regulation, decrease suicidal ideation/attempts and self-harm
behaviors), or they may be different based on your population. For example, if you
are working with adolescents who struggle with depression and anxiety, your targets
will likely include the reduction of panic attacks and depression-related symptoms.
Regardless, utilizing a formalized assessment can be helpful for creating measured
progress.
24
There are several instruments that are traditionally used in DBT, and many of these
are discussed in subsequent chapters in this book. It is important to ascertain which
assessment best fits the needs of your program. As with all assessments, be sure that
you (or whoever will be administering the assessment) fully review the instructions
for administration and scoring, as well as the reliability, validity, and norming group
information.
Overall Program Evaluation

Though you likely will use assessments to measure client progress, it is also import-
ant to engage in an overall evaluation of your program. There are several ways to
approach this process. First, a collective analysis of your clients’ assessments can give
you an overall sense of whether your program is effective. You can also use satis-
faction surveys, individual interviews, and focus groups, as they may provide further
insight directly from the clients. Taking these steps will help you make adjustments to
increase positive outcomes in your program. It will also help you show positive prog-
ress to administrators and other stakeholders, which will hopefully increase support
and investment.
MULTICULTURAL CONSIDERATIONS
Unfortunately, there is very little published on using DBT with different cultures. How-
ever, DBT is a flexible approach, and adaptations for diversity can be done intention-
ally, as long as you are mindful of your cultural worldview, knowledge, and skills, as
well as those of your client (Ratts, Singh, Nassar-McMillan, Butler, & McCullough,
2016).
The majority of research on DBT with diverse cultures is related to clients of His-
panic descent. For example, one adaptation described two new parent-adolescent
dialectical dilemmas that can occur between the parents and children in Latino fam-
ilies (Germán et al., 2015). The first dialectical dilemma, old school vs. new school,
discusses the polarization between the parents’ traditional beliefs from their own
country (children should be obedient and not question their parents) and the adoles-
cent’s beliefs based on the culture they currently reside in (I should have the freedom
and responsibilities that my friends have). The second dialectical dilemma, over-pro-
tection vs. under-protection, describes the juxtaposition between parents who do
not give their children any freedom (due to fear and beliefs that the world is unsafe,
often because they came from a country that was not safe) and the parents who
expect their children to take on too many responsibilities (for example, being required
to watch younger siblings every day). For both of these dilemmas, it is important to
validate the experiences of both parents and adolescents, and work to help them find
the middle path via compromise and empathy (Germán et al., 2015). Other research-
ers used loteria cards for contingency management, and common Latino idioms and
fables to help clients understand the DBT skills and aspects (McFarr et al., 2014). They
25
also treated each client with respect and warmth common in Latino interpersonal
interactions.
Another study adapted DBT for Native American adolescents. They implemented
traditional DBT; however they also included a local spiritual counselor to regularly
conduct traditional Native American spiritual practices, including sweat lodge cere-
monies and talking circles (Beckstead, Lambert, DuBose, & Linehan, 2015). This study
supports other research that suggests that by incorporating a culture’s traditional
spiritual healers into mental health treatment, you can increase clients’ acceptance
and compliance with treatment (Bledsoe, 2008). For example, if there is a church that
largely serves Hispanic constituents, you may be able to work in collaboration with
their pastor to promote the benefits of DBT treatment, as well as provide support and
education to the community.
Multicultural considerations are not limited to race and ethnicity. Adolescents’
gender identity, disability status, and socioeconomic status (SES) may also warrant
treatment adaptations. For example, in one study, lower SES adolescents did not
experience any differences in treatment outcomes compared to their higher SES
counterparts; however, they did experience more problems with treatment com-
pliance (James et al., 2015). Providing resources when possible (for example, bus
passes), conducting reminder phone calls, and planning in the beginning for any
possible barriers to treatment can help combat this. Communicating with parents and
guardians may also be important, as they may often have additional stressors with
work and finances that may affect compliance. Depending on your setting, the ability
to provide food and/or childcare as needed could increase treatment compliance.
Gender identity may be an important consideration if you offer single gender groups,
as transgender clients may be in the process of transitioning, or simply not ready to
solidify themselves as one gender or another. This can limit their ability to take part in
DBT groups if they are aligned by gender; however if you offer mixed gender groups,
this problem can be avoided. You also may need to make accommodations for clients
with disabilities such as visual and hearing impairments. This can include providing a
sign language interpreter, seeking out resources in braille, or providing skills teach-
ing in individual sessions to increase comprehension. Regardless of the adaptations
you make for diversity purposes, be sure to elicit feedback from clients, collaborate
with your consultation team to maintain the fidelity of the treatment, and conduct
program evaluation and assessment to be sure your program continues to meet iden-
tified treatment targets.
CONCLUSION
There is a lot of groundwork to cover before implementing a DBT program. In eager-
ness to get started, many clinicians may wish to jump in and start providing services
ASAP. However, it is first important to consider how DBT will be applied, with con-
sideration to the setting and population, as well as the modes, functions, and stages
of treatment (see Chapter 1). Once you have made these choices, and decided how
26
you will evaluate individual progress as well as programmatic progress, then remem-
ber obtaining at least partial commitment from the client and his or her family to
treatment is important. Spending this time in the pretreatment phase will increase
compliance, as will engaging in recommitment as necessary throughout treatment.
Finally, remember that after implementation you can continue to make adaptations
as needed to ensure the success of your program and your clients.
REFERENCES
Beckstead, D. J., Lambert, M. J., DuBose, A. P., & Linehan, M. (2015). Dialectical behavior
therapy with American Indian/Alaska Native adolescents diagnosed with substance use
disorders: Combining an evidence based treatment with cultural, traditional, and spiritual
beliefs. Addictive Behaviors, 51, 84–87. doi:10.1016/j.addbeh.2015.07.018
Bledsoe, S. E. (2008). Barriers and promoters of mental health services utilization in a
Latino context: A literature review and recommendations from an ecosystems per-
spective. Journal of Human Behavior in the Social Environment, 18(2), 151–183.
doi:10.1080/10911350802285870
Germán, M., Smith, H. L., Rivera-Morales, C., González, G., Haliczer, L. A., Haaz, C., & Miller,
A. L. (2015). Dialectical behavior therapy for suicidal Latina adolescents: Supplemental
dialectical corollaries and treatment targets. American Journal of Psychotherapy, 69(2),
179–197.
Hunnicutt Hollenbaugh, K. M., Klein, J. M., & Lewis, M. S. (2015). Implementing dialecti-
cal behavior therapy (DBT) in your practice—standard DBT vs. DBT informed. Counseling
Today, 58(2), 40–45.
James, S., Freeman, K. R., Mayo, D., Riggs, M. L., Morgan, J. P., Schaepper, M. A., & Mont-
gomery, S. B. (2015). Does insurance matter? Implementing dialectical behavior therapy
with two groups of youth engaged in deliberate self-harm. Administration and Policy
In Mental Health and Mental Health Services Research, 42(4), 449–461. doi:10.1007/
s10488-014-0588-7
McFarr, L., Gaona, L., Barr, N., Ramirez, U., Henriquez, S., Farias, A., & Flores, D. (2014). Cul-
tural considerations in dialectical behavior therapy. In A. Masuda (Ed.), Mindfulness and
acceptance in multicultural competency: A contextual approach to sociocultural diversity in
theory and practice (pp. 75–92). Oakland, CA: Context Press/New Harbinger Publications.
Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2016). Mul-
ticultural and social justice counseling competencies: Guidelines for the counseling profes-
sion. Journal of Multicultural Counseling and Development, 44(1), 28–48. doi:10.1002/
jmcd.12035
27
3
Treatment Team and Continuity of Care
and Jacob M. Klein
DBT includes a range of services provided by a team of professionals. In this chapter

we will focus on the roles of various DBT team members, and outline their unique
contributions to the client’s success in treatment. The composition of your treatment
team will vary based on the setting you work in, and the population with whom you
are working. You may also find that one individual on the treatment team fulfills more
than one role. Regardless, there are a lot of factors to consider, including training,
availability, and commitment to the DBT model. As the setting and team members
may change over the course of treatment, we will also address best practices for con-
tinuity of care in this chapter.
TREATMENT TEAM MEMBERS AND ROLES

Your treatment team will comprise of anyone who is involved in providing any mode
of DBT to the adolescent. This can include counselors, psychologists, psychiatrists,
and mental health technicians. Remember, the goal is to work collaboratively as a
team and meet weekly for consultation. Everyone on the team should have received
some sort of training in DBT, though there are a lot of different ways to provide this.
In general, it is best practice for at least the treatment team leader to have received
intensive (40–80 hours) training (Miller, Rathus, & Linehan, 2007).
Other providers in the community can also be considered ancillary team members.
A team member can be anyone who is aware of the client’s treatment goals, and also
has an understanding of the basic fundamentals of DBT (Linehan, 1993). Many of
your clients may be receiving other services—for example, medication management
by a psychiatrist or licensed nurse practitioner, or case management through a local
nonprofit agency. Regardless, these other providers are only considered treatment
team members if they are committed to fulfilling DBT treatment goals, and are work-
ing collaboratively with other team members. For example, a case manager who
refers a client for hospitalization every time he or she expresses thoughts of suicide
would not be working in alignment with the DBT model to reinforce positive cop-
ing skills use. Instead, by hospitalizing the client immediately, the case manager has
reinforced the use of inpatient hospitalization as a method of coping with emotion
dysregulation.
29
K. Michelle Hunnicutt Hollenbaugh et al.
See Table 3.1 for a list of possible treatment team members, including ancillary
team members. We will review the most pertinent in this chapter; however other team
members that may be specifically related to a setting or diagnosis will be reviewed in
the corresponding chapter.
Your client should be aware of all the professionals involved in his or her treatment,
and the role of each of these members, regardless of the setting. We have included
handouts (Handout 3.1 and Handout 3.2) that may be helpful, and can include infor-
mation on team members, how they will be working with the client, and how to
contact them if needed.
Table 3.1 Treatment Team Members and Roles
Team Member Role
Primary Team Members

Team Leader This person likely serves more than one role, but as the team
leader he or she maintains the fidelity of the treatment,
manages consultation team meetings, and any other
administrative concerns related to providing DBT.
Primary Clinician Addresses treatment targets, behavioral problem-solving.
Intersession skills coaching.
Skills Trainer Teaches skills and enhances use.
Case Manager Addresses secondary treatment targets and advocacy for the
client, consultation to the client.
Ancillary Team Members
School Counselor Assists in skills generalization, consultation to client,
intersession skills coaching.
Psychiatrist Provides medication management, assists in skills
generalization, and reinforcement of skills use.
Probation Officer Assists in generalization and reinforcement of skills use,
monitoring and extinction of problem behaviors. Intersession
skills coaching.
Nurse Provides medication management, consultation to client,
intersession skills coaching.
Mental Health Technician The rest of these members may assist in generalization and
Sports Coach reinforcement of skills use, extinction of problem behaviors,
and intersession skills coaching.
Pastor
Dietician
Physician or Other
Medical Specialist
30
Team Leader
The team leader has a lot of responsibility, and may also have several different roles.
As the team leader, he or she will be expected to have the most training, and be
sure the other team members have adequate training as well. He or she will also be
in charge of maintaining the fidelity of the treatment, ensuring consultation team
meetings take place, and that the team stays on task during meetings. Finally, the
team leader manages any other administrative duties or concerns regarding the DBT
treatment. For example, as the team leader for my DBT treatment team, I regularly
need to make in-the-moment decisions about concerns that might arise. This can
include client concerns that cannot wait until consultation team meetings, logistics of
program evaluation, and contact with members of the community.
Skills Trainer
The primary role of the skills trainer is to help the client learn new skills, and use them
in all areas of his or her life. The skills trainer is usually a different person than the
primary clinician that meets with the adolescent and family for individual and family
sessions. Linehan (2015) noted that it might be more difficult for the primary coun-
selor to switch to skills trainer mode and vice versa. By having a different individual
in each role, it makes it easier for them to focus on their specific treatment targets.
Skills trainers facilitate the psychoeducational skills group, and monitor homework
and diary card completion. They may address therapy-interfering behaviors that are
specifically related to group attendance and participation. They may also be available
for intersession phone coaching. If there are additional therapy-interfering behaviors,
or concerns regarding the client, the skills trainer will consult with the primary clini-
cian, who will address these concerns in the next individual or family session (Linehan,
2015).
Primary Clinician
The primary clinician is responsible for decreasing problem behaviors, and gener-
alization of new skills. He or she conducts the individual (traditionally held weekly)
and family sessions (as needed) (Miller et al., 2007). During individual sessions the
primary clinician will begin by reviewing the diary card, then work with the client to
conduct behavior chain analyses related to problem behaviors they engaged in that
week. For example, if one of the client’s identified treatment targets is to decrease
self-harm, and the client indicated on his or her diary card that he or she engaged
in self-harm on two days that week, two separate chain analyses will be conducted
for each separate incident. Linehan emphasizes the point that diary cards and prob-
lem behaviors should be addressed first, before you can move on to topics the client
wishes to discuss. This approach can help you extinguish problem behaviors via nega-
tive reinforcement. Throughout, be sure to use DBT treatment strategies and regularly
balance validation and change.
31
Case Manager
Though case management is not a service provided in all settings, it is fairly common,
especially in community mental health centers. If your organization does provide case
management, optimally, the case manager will be a fully trained member of the DBT
team and attend regular consultation meetings. It is also possible that the adolescent
may be receiving case management at a different agency. In this situation, the case
manager would become an ancillary team member, but hopefully would at least have
a basic knowledge of the DBT model and the client’s treatment goals.
Case managers are in charge of many aspects of care, but primarily they focus
on coordinating and linking the client to resources (housing, adjunct services, food,
clothing) and treatment. They also may help with scheduling meetings, acting as
a liaison between treatment providers, and providing assistance in crisis situations.
However, it is essential for the case manager to be aware of the importance of provid-
ing consultation to the client. This refers to the process of coaching and empowering
the adolescent to advocate for him or herself, instead of doing it for him or her. For
example, if the adolescent tells the case manager he or she would like to change the
next appointment time with the primary clinician, instead of calling the primary clini-
cian for the client, the case manager should help the adolescent identify skills that he
or she can use to make this call him or herself. Truthfully, all team members should
be aware of and use consultation to client; however, it’s particularly salient for case
managers, as their main role is facilitating services and advocating for the client. If
the case manager has concerns or questions about the adolescent’s ability to advo-
cate for him or herself in a given situation, this should be presented and discussed in
consultation team meetings.
Physician
Though it may be rare that the client’s medical doctor is actively involved in treat-
ment, this might occur if the adolescent has a chronic health condition that needs
regular monitoring, or perhaps receives psychiatric medications via a primary care
physician. In either case, it is important the doctor is aware the adolescent is receiv-
ing DBT treatment, and aware of his or her treatment targets. This can be espe-
cially true if some of the client’s problem behaviors are medically related. This can
include medication noncompliance (not taking medications as prescribed, or taking
too much or too little), dietary noncompliance (for example, a client who is diabetic
not adhering to a prescribed diet), or use of medication as a form of self-injury (this
can also be exhibited in the form of taking more or less than prescribed). See Hand-
out 3.3 for a worksheet that can help parents and adolescents keep track of their
medication compliance.
It may also be the case that the client is not actively involved with a doctor when
he or she begins DBT, but it then becomes clear that he or she would benefit from
medical attention. Hopefully then you will be able to make an appropriate referral to
a physician who is aware of DBT and will work closely with the treatment team.
32
Psychiatrist
Depending on the setting you work in, you may or may not provide in-house psy-
chiatric services. If there is a psychiatrist on site, optimally, he or she will attend DBT
consultation team meetings and be actively involved in providing DBT treatment.
If a psychiatrist within a different organization provides pharmacological services,
you will want to facilitate regular communication with the treatment team. In
some ways, communication with the psychiatrist is more important than commu-
nication with other ancillary team members, as treatment goals and medication
can be strongly interrelated. For example, your client may only have an appoint-
ment with his or her psychiatrist once every few months. As result, the primary
clinician and other consultation team members may be first to notice any adverse
side effects or problems related to medication. In addition, the adolescent’s weekly
diary card may be important information for the psychiatrist to have access to, as it
will contain a daily rating of the adolescent’s emotions, symptoms, and medication
compliance.
Other Ancillary Team Members

Other individuals who may be involved in the DBT are listed in Table 3.1, and will be
covered in corresponding chapters. Please be aware that this list is not exhaustive—
depending on the population you work with, there may be any number of adults and
professionals who can be involved in helping the client reach his or her treatment
goals. You can ascertain who these individuals are through the initial biopsychosocial
assessment. Ask the client and his or her parents about mentors, extra-curricular
activities, and any other family members that may serve an important role in the
client’s life. For example, even though grandparents may not necessarily be a part of
family sessions and skills training, if the adolescent has a close relationship with one
or both of them, it is still important that they are involved in facilitating the adoles-
cent’s success.
CONTINUITY OF CARE
It is possible (or, depending on your setting, likely) that the needs of your client may
change during the course of treatment, and as result, he or she may be transitioned to
more intensive or less intensive care. Continuity of care refers to providing a smooth
transition for clients when moving through different levels (higher or lower intensity)
of care related to his or her treatment needs (Guiford, Naithani, & Morgan, 2006).
This can be especially important when providing DBT treatment, due to the interdis-
ciplinary nature of the treatment team.
Decisions regarding changes in the level of care the client receives can be difficult
to make, and should be made collaboratively with your consultation team, the ado-
lescent, and his or her parents. As the goal of DBT is to facilitate the client’s ability
33
to engage in positive skills use instead of engaging in problem behaviors (which are
often life threatening), facilitating the client’s ability to continue to use and learn
those skills should be a primary consideration. For example, if the client is transition-
ing from an inpatient setting to a partial hospital, intensive outpatient, or even out-
patient setting, you and your team will want to do your best to find a provider that
provides DBT treatment. This could include a referral to outpatient DBT treatment
while simultaneously referring to a partial hospital or intensive outpatient setting that
either provides DBT or is aware of the DBT and can continue to support the adoles-
cent’s treatment goals.
Similarly, if the team decides the client is in need of a higher level of care—for
example, from outpatient treatment to inpatient hospitalization—you will need to
be able to communicate the client’s treatment goals to inpatient providers, as well as
behavioral targets. If a client is hospitalized, traditionally the client should not have
any contact with the clinician until he or she is discharged. The goal of this limitation
of contact is to reduce the reinforcement (often increased love and attention) the
client might receive from being hospitalized. It can be especially difficult to facilitate
communication when the client is transitioning between levels of care, and this is a
time that Handout 3.5, which discusses the basics of DBT and the client’s treatment
targets, may come in handy.
CHALLENGES AND SOLUTIONS
Confidentiality and Releases of Information

One challenge you will undoubtedly face is attaining the proper documentation to
communicate with other professionals and relevant family members. We’re sure
you’re familiar with the Health Insurance Portability and Accountability Act (HIPAA,
hhs.gov, 2016), which makes it illegal to disclose any health or treatment information
without written consent by the adolescent’s parents. Though many of your clients
may be more than happy to sign a release of information for you or other providers
to disclose information to each other, others may be more reluctant to do so. This
could be for a variety of reasons, including concerns about who will be able to see
their records, and what will be done with those records. These concerns can often
be alleviated by taking the time to explain to the client’s parents what they will be
signing, why it is important, and their rights to rescind the written release of informa-
tion at any time (see Handout 3.4 for a form explaining confidentiality). If the client’s
parents are willing to sign a release, it will often include an expiration date. Therefore,
a team member should be charged with ensuring that all necessary documentation
is updated regularly.
In the event that the client’s parents are still unwilling to sign a release of infor-
mation, you can ask them to personally communicate the necessary information. If
they are willing, you can work together to complete a brief form that describes the
basics of DBT, the client’s treatment goals, and the skills he or she is working on (see
34
Handout 3.5). Similarly, if they are willing, you could give them a blank form for the
other professional to complete and send back to you via the client and his or her
guardians. This form could include anything the other professional would want the
DBT team to know, or any questions the other professional has (see Handout 3.6
for an example). In the event the client is willing to facilitate this communication, it
is imperative that any information shared between the professionals is directly pro-
vided via the client, as without a written release of information, it would be illegal
for you to communicate or send this documentation directly.
Therapy-Interfering Behaviors by Ancillary Team Members

Though all team members can fall prey to therapy-interfering behaviors, ancillary
team members may be especially susceptible, as they may have limited experience
and training related to DBT. These therapy-interfering behaviors will likely come in the
form of reinforcing behaviors the client has been working to extinguish. For example,
let’s say your client is working to decrease self-harm behaviors, and she voices that
she is having thoughts of harming herself to her psychiatrist. You would hope that
her psychiatrist would either engage her in skills coaching, or encourage her to call
her therapist for skills coaching over the phone. However, what may happen instead
is that the psychiatrist immediately starts the process to have the client hospitalized.
This unintentionally reinforces the problem behavior, and the client may be less likely
to focus on using her skills in the future.
Therapy-interfering behaviors can also occur when an ancillary team member fails
to engage in consultation to the client (see above under case manager). As another
example, say your client tells his school counselor that he is having a problem with
his therapist. Again, your hope would be that the school counselor would coach the
client through addressing the problem directly with the therapist. However, instead
the school counselor may contact the therapist herself to discuss the issue. When this
happens, the client misses an opportunity to use his skills to advocate for himself.
Instead, he is reinforced for going to others for advocacy, and this also can cause rifts
between team members, as the school counselor will then seem aligned with the
client against the therapist.
Most therapy-interfering behaviors can be prevented (or extinguished) by clearly
communicating to the team member the adolescent’s treatment targets, and how
they can help the client increase skills use. However, regardless of the amount of
information you share, there may be treatment providers who are simply unwilling
or unable to align with the DBT approach. If this happens, the consultation team will
want to work with the adolescent and his or her parents to discuss the issue and any
possible solutions.
(Mis)Communication
Perhaps one of the most difficult challenges in DBT is maintaining communication
between team members, the client, and the client’s parents. Part of the informed
35
consent the adolescent and his or her parents complete should explain the role of the
consultation team and the communication that will take place between members of
the DBT team at your site. This should also include the basics of confidentiality, and
the limits to that confidentiality. Once this has been clarified as an important aspect
of DBT treatment, it will be your responsibility to be sure that the communication
between team members is done effectively and confidentially. This can be done via
a form that is completed and placed in the client’s file. Then, anyone involved in the
client’s treatment will be able to see this note and be aware of any concerns (see
Handout 3.7). Similarly, any major concerns should be brought up and addressed
during consultation team meetings.
Miscommunications can arise when information or issues regarding a client are
not shared with everyone on the team. For example, if the skills trainer has a concern
about the client’s possible substance use, and shares his or her concerns with the
primary clinician, but not the case manager, the case manager then may not know to
watch for warning signs of substance use. Similarly, if the concern is communicated
from one team member to another without the original team member writing out the
concerns, some of the information may be inadvertently changed or left out much
like the game telephone (a game played with a group of children—one child starts a
message that is whispered into the next child’s ear, and once each child has passed
the message on, the last child says the message out loud. Usually, by the time the last
child states the message, it has significantly changed from the original message!).
Training
Training is an important consideration for the DBT treatment team (see Chapter 2).
Members who will be directly implementing treatment need to be fully trained in the
model in order to ensure fidelity and best practices (Miller et al., 2007). However, you
may be conflicted as to the best way to provide this. The amount of training team
members who are not providing direct care should have to maintain the fidelity of
the treatment will vary based on the population, the setting, and also the resources
you have for training. If your site does not have a lot of funding for training, there
are many options for self-study. There may also be concerns about providing training
for new team members that join after the DBT program has started. Though it can be
challenging, setting a formalized structure for all team members to receive adequate
training will save you problems later on.
SUMMARY
There are a number of professionals that can be involved in your adolescent’s treat-
ment team. As always, this will vary based on your site and the population with which
you work. Not only is it important that each team member knows his or her roles, but
it is also important that adolescents and their parents are aware of the role each pro-
fessional plays. Communication with ancillary treatment providers can be tricky, but it
36
is necessary for the adolescent to generalize skills use. Problems can arise when ancil-
lary team members are not properly informed of the DBT approach and the client’s
treatment goals. Our hope is that the handouts provided in the Handouts section will
facilitate your ability to effectively and efficiently communicate with other providers.
REFERENCES
Guiford, M., Naithani, S., & Morgan, M. (2006). What is ‘continuity of care’? Journal of Health
Services Research & Policy, 11(4), 248–250. doi: 10.1258/135581906778476490
hhs.gov (2016). Health information privacy. Retrieved from www.hhs.gov/hipaa/
37
4
Outpatient Settings
In this chapter we will discuss implementing DBT for adolescents in outpatient set-
tings, including community mental health agencies and private practice settings. The
majority of research on DBT is related to outpatient settings (MacPherson, Cheav-
ens, & Fristad, 2013). However, there are so many differences based on setting, you
will still have to consider what DBT will look like for your clients, and program evalu-
ation will be essential to verifying that your clients are reaching their treatment goals.
CONSIDERATIONS BEFORE IMPLEMENTING DBT

As we’ve already discussed in Chapters 1–3, there are a lot of factors to consider
when implementing DBT. Outpatient settings require less adaptations; however,
you’re going to need to make a lot of decisions. For example, will you be implement-
ing standard DBT or adapted DBT? What population will you be targeting, and what
will the goal of DBT be? If you decide to adapt, remember to review the first couple
chapters so you are sure you are covering all of the treatment targets, even if you are
only offering one or two modes of treatment (for example, only individual treatment
or only skills group).
Private Practice
Clinicians implementing DBT in their private practice face unique challenges. It may
be difficult to implement standard DBT, especially with limited team members to pro-
vide the multimodal treatment. Some independent clinicians in private practice offer
individual and group DBT treatment, and then offer phone coaching during limited
hours. If you do not have enough clinicians to form a DBT consultation team within
your private practice, remember you can form or join a team in the community, with
other clinicians in their private practice or community mental health settings (see
Chapter 3 for more on forming consultation teams).
Community Mental Health

In some ways, implementation of DBT in community mental health (CMH) settings
is easier than private practice because there are often fewer limitations with regard
to billing. Often clients receiving treatment in CMH have Medicare or Medicaid, and
39
these programs do not have limits on services the way other third-party insurance
companies often do (Ben-Porath, Peterson, & Smee, 2004). On the other hand, it
can be more difficult to fit the program into an existing system, especially when
administrators do not understand the behavioral principles of DBT and the benefits
of the multimodal approach. If you find yourself in a situation in which your admin-
istrators are not supportive of developing a DBT program, you may need to conduct
a needs assessment ahead of time. By doing this, you can show your administrators
the importance of the program, and the match between DBT and the needs of the
population you serve (Carmel, Rose, & Fruzzetti, 2014).
Traditional Treatment Targets With Adolescents

See Table 4.1 for the hierarchy of treatment targets in DBT and examples for standard
DBT. We will include this table in the majority of the other chapters in this book, and
give different examples based on the setting and population.
You can use the My Target Behaviors handout with your client to identify and
address specific treatment targets (see Handout 4.1). It can be completed by the cli-
ent during individual sessions and should be focused on both the introduction of new
behaviors or specific DBT skills, and reducing problematic behaviors. This handout can
be completed in conjunction with the behavior chain analysis to help you and your
Table 4.1 Traditional DBT Treatment Targets and Hierarchy
Treatment Targets Examples
Primary Treatment Targets

Life-Threatening Behaviors Urges, thoughts, or behaviors that harm self or others
Therapy-Interfering Not completing homework
Behaviors Arriving late to session
Not attending session
Angry or irritable mood
Argumentative or defiant behavior
Parents:
Not providing transportation to treatment
Not attending treatment
Not engaging in or attempting to practice skills
Interfering with others in group
Quality-of-Life-Interfering Substance use
Behaviors Risky sex
Impulsivity
Academic issues
Parents:
Being punitive
40
Outpatient Settings
Increasing Behavioral Skills Mindfulness

Emotion Regulation
Distress Tolerance
Secondary Treatment Targets
Dialectical Dilemmas Parents allowing the adolescent to not return home
Excessive Leniency vs. several nights of the week, then suddenly grounding the
Authoritarian Control adolescent for six months.
Active Passivity vs. The adolescent will not use skills at all vs. attempting to
Apparent Competence manage crisis situations when he or she actually needs
guidance.
Unrelenting Crises vs. Client vacillates from either constantly experiencing
Inhibited Experiencing emotional crises (discord with parents and friends, problems
in school) to cutting him- or herself off from all emotions
completely (suppressing).
clients work together to identify problem behaviors, and find ways to reinforce new
positive coping skills.
Diary Cards
In addition to the behavior chain and the treatment targets handouts, see Handouts
1.2–1.5 for several adapted versions of the DBT diary card. The diary card is essen-
tially a journal the client completes daily and brings to session every week. It includes
a list of skills the client has learned, emotions the client has experienced, any target
problem behaviors, and related treatment targets. The client then indicates the day
he or she engaged in the skill or behavior, or rates how much he or she experienced
an emotion or urge. We have included an adaptation of the diary card for some of
the chapters in this book or you can adapt these cards with your specific needs. It is
essential that the client understands the importance of the diary card, and commits
to completing it. At first, the diary card can look overwhelming, so instead I usually
have the client start small, and track one or two things for the week. Once the client
has become accustomed to the process, we begin to slowly add more skills/behav-
iors to track. In traditional DBT, the client brings the diary card to individual sessions,
and then you will discuss any problem behaviors that the client engaged in over the
week—and then complete a behavior chain for each of those behaviors. The client
may also bring the diary card to skills group; however, this will only be to discuss skills
use from the previous week, not problem behaviors (Linehan, 2015).
If the client has not completed the diary card, then he or she must take time
in session to complete it, and you should not give the client attention during this
41
time—instead work on paperwork or keep yourself busy doing something else. The
goal is to be sure that you are not reinforcing the client for not completing the
diary card. I have a colleague who will actually sit and read a magazine while clients
complete unfinished diary cards! Conversely, when the client does complete the
diary card and bring it in, it is important to positively reinforce this with praise and
celebration.
It’s usually best if the client finds a regular place to keep the diary card—for exam-
ple, beside his or her bed. The adolescent should then set a time that he or she will
complete the card daily—usually right before bed works well, but any time is fine, as
long as it is completed. There are also smart phone apps that have DBT diary cards
that are customizable—this may be more appealing to adolescents, and therefore
they may be more likely to complete them.
STANDARD SKILLS MODULES FOR ADOLESCENTS

As we mentioned in Chapter 1, there are five standard skills modules in DBT for ado-
lescents (Miller, Rathus, & Linehan, 2007). You can decide which skills to teach your
clients, and in what order you wish to teach them in. This will vary based on your cli-
ents’ treatment targets—for example, if you have a lot of clients who engage in very
serious life-threatening behaviors, you may want to focus on distress tolerance skills,
so they can start using those skills to reduce those behaviors. We will cover a few of
the skills from each module that we believe can be the most helpful for adolescents,
and are easily adapted for a variety of treatment targets.
Mindfulness
Mindfulness is by far the most important skill in DBT, as it underlies all of the other
skills. There are mindfulness exercises throughout all of the skills modules, and the
majority of DBT skills include some aspect of awareness in the present moment. It’s
important that you teach this skill early, and encourage adolescents to practice it
often. See Handout 4.2 for a list of some of our favorite mindfulness exercises. What
I love about mindfulness in DBT is that it is not limited to the traditional mindfulness
meditation of sitting quietly and focusing on breathing. Literally any activity can be
considered practicing mindfulness, as long as the adolescent is focused on that one
thing, in the moment, and nothing else. I encourage my clients to find an activity
they do every day, and be mindful during that activity. That can be showering, doing
chores, or driving (an optimal one!). You also can have fun with mindfulness in ses-
sion. Linehan (2015) and Rathus and Miller (2015) highlight some interactive mindful-
ness activities that are frequently used in DBT—for example, singing Row, Row, Row
Your Boat in a round (with hand movements) or “mirroring” a partner’s movements
silently. I’ve also found that a lot of activities involved in improvisation (improv) acting
can be used as interactive mindfulness practice—as well as games that test adoles-
cents’ ability to think quickly.
42
Outpatient Settings
DEAR MAN
Linehan (2015) developed this acronym to help clients assertively ask for something
they want, or say no to a request. This can be an important skill for adolescents, who
may not have been taught how to communicate assertively, or may be struggling
with emotion dysregulation and therefore not be able to think objectively in the
moment (see Handout 4.3 for a worksheet on interpersonal effectiveness myths). The
acronym stands for Describe, Express, Assert, Reinforce, stay Mindful, Appear confi-
dent, and Negotiate (see Handout 4.4). When you teach this skill, your goal will be to
help your clients remember the acronym, identify situations in which they might use
DEAR MAN, and help them practice in session (group or individual, depending on the
format of your DBT program) so they get a feel for going through the steps. When
I have had clients practice in group sessions, I usually have them pair up and work
together, and then switch, so each client has the opportunity to role-play the person
using the acronym, and role-play the person listening. I usually allow them to choose
a situation they want to role-play, or I will give them one if they have trouble thinking
of one. For example, a friend consistently borrows clothes but doesn’t return them,
and the client needs to request that the friend return the clothes. They usually have
a lot of fun with it, and if the “receiving” person is difficult, it is a good opportunity
for the adolescent to use a broken record technique, and practice maintaining an
assertive approach. I also remind them that DEAR MAN can also be used via email and
text message, which can be helpful as they would have more time to think through
each step.
The part of this skill that my clients struggle the most with is the fact that they can
use the acronym perfectly; however, they still cannot control the other person. So,
even though they are assertive in an attempt to get their needs met, this does not
mean that the other person will receive it well, or comply with the request. You will
want to discuss this with your clients, and discuss distress tolerance skills they can use
in the event that this does happen (Linehan, 2015).
Emotion Regulation
What Emotions Do for You

There are a lot of skills in the emotion regulation module. However, I have found
that my clients have the most insight when we discuss what emotions are, and why
we have them (see Handouts 4.5, 4.6, and 4.7). This sounds simplistic, but I am
always surprised at how many people aren’t aware of this basic information—and
how absolutely empowering it can be. It can be really helpful for clients to know that
their emotions aren’t bad—even anger or sadness. What can be harmful and/or have
consequences are the behaviors we engage in as result of those emotions. We also
discuss the difference between primary and secondary emotions, which can also be
43
surprising for adolescents to realize that anger can be a secondary emotion to hurt
or sadness. In this discussion, I usually have the clients give examples of times that
emotions have been helpful for them, and compare the differences between those
times and the times when they were not helpful. We can then go on and talk about
the skills they can use to decrease their vulnerability to emotions, and increase posi-
tive emotions.
Acting Opposite
This skill is extremely flexible, and we have adapted it (and highlighted others’ adap-
tations) in a few of the other chapters for specific treatment targets. The premise
of this skill is that adolescents will identify the action they wish to engage in that is
related to their current emotion (anger, sadness, jealousy) and do the exact opposite.
So, for example, watching a funny movie when sad, or doing something nice and car-
ing for someone else when angry. Adolescents can work together in group sessions
to generate ideas for activities that are the opposite action of a few emotions. This
can be fun (and can get silly) and then after they have generated the list together (for
example, on a whiteboard), they can take a picture of it on their phones so they have
it when they need it (see Handout 4.8).
Cope Ahead
This is another skill you will see in some of the other chapters in this book. In this skill,
adolescents are encouraged to imagine situations that may come up in the future
that they will need to use coping skills instead of engaging in a problem behavior.
Then they actually practice imagery and imagine themselves in the situation, using
their skills (see Handout 4.9). I like this skill because it helps adolescents actually use
the skills when they need it. I have often found that we talk about skills, and clients
are very receptive to them in session, but then forget to use them in the moment.
With this skill, they identify the specific situation in which they will use skills, and then
actually imagine it happening, which increases the likelihood of skills use.
Distress Tolerance
Radical Acceptance
This is my favorite distress tolerance skill. It’s especially useful for adolescents because
there are a lot of things in their life that they cannot control. In this skill, adoles-
cents are encouraged to accept reality to reduce suffering associated with some-
thing painful (see Handout 4.10). You will want to emphasize that acceptance does
not equal approval—there are a lot of situations we do not approve of, but we still
need to accept reality. Not only do we suffer when we refuse to accept pain, but we
also can’t do anything to change what we can control until we accept the situation.
Sometimes this skill is difficult for adolescents to grasp, due to the nuances in the
44
Outpatient Settings
wording (it is difficult to let go of the association between the words accept and
approve). However, I like it because it can align with some spiritual beliefs—for exam-
ple, the belief that “God has a plan” can go along with acceptance. Regardless, there
are some situations that are extremely difficult to accept—for example, the death
of a loved one. In this case, it will be important for you to emphasize that radical
acceptance is acceptance of every aspect of that situation—including the part of the
adolescent that does not wish to accept the situation at all.
STOP
This skill is perfect for adolescents—I like to think of it as thought stopping for behav-
iors (behavior stopping!). The goal is for the adolescent to be able to imagine a
stop sign and stop in the moment, before engaging in a problem behavior. This can
especially be helpful for clients who have problems with anger and fighting (see
Chapter 7). After stopping themselves in the moment, they then use mindfulness
to increase awareness of the situation, and make a decision regarding how to go
forward. This is another skill that can be fun to practice in session—either having the
client role-play the situation and use the STOP skill, or some other activity to empha-
size the point of stopping suddenly in the moment. For example, a colleague of mine
will have group members walk around the room in a circle and then yell “Stop!”
(they stop), “Take a step back!” (they take a step back), “Observe!” (they mindfully
observe in the moment), and then “Proceed mindfully!” (they continue to walk in the
circle, and then do this once or twice more).

Miller et al. (2007) developed Walking the Middle Path as a skills module to specif-
ically address the parent-child relationship. There are three main skills taught in this
module: dialectics, validation, and behaviorism. These skills can definitely be helpful
for adolescents individually; however, they are most effective when taught to parents
and adolescents together, as then they are able to work together to use the skills
outside of session.
Dialectics and Dialectical Dilemmas

We have already discussed dialectics and dialectical dilemmas in detail in Chapter 2,
so refer back to that section as needed. However, in the Walking the Middle Path
module, the focus is on teaching adolescents and parents about dialectics, and how
they can fall into patterns related to the dialectical dilemmas. This may be a more
difficult task. See our handouts on Dialectical Dilemmas and Walking the Middle Path
in Handout 4.11 and Handout 4.12, respectively. The main idea to communicate to
your clients is that two seemingly opposite points of view can both be correct. Once
they have grasped that idea, they can work together to see each other’s point of view,
which will improve their relationship tremendously. Sometimes what has been helpful
45
for me is to have them give examples of their point of view in conflicts they have had:
for example, if the adolescent’s point of view is “I believe I should be able to stay out
later because I am old enough to take care of myself” and the parent’s point of view is
“I do not believe you should stay out later because I am concerned about you and you
still aren’t an adult,” you can help them see the truth in both of those statements, and
hopefully by understanding each other further, they can reach a mutual agreement.
Validation
Once you have taught your clients about dialectics and seeing the truth in both sides,
you will want to teach them how to validate each other. This is a skill that clinicians
in helping professions often take for granted. We do this all the time, so it often
becomes second nature. I sometimes forget that a lot of people aren’t even familiar
with the term! It will be important for you to spend some time teaching your clients
and their parents not only about self-validation, but validating others as well (see
Handout 4.13 in the back of the text). In addition to teaching them why it is import-
ant to validate, and how to do it, you also want to be clear about what NOT to vali-
date (namely, the problem behavior itself). Finally, you can always find something to
validate, even if you do not want to validate behavior, you can validate emotions, or
you can validate their past experiences that may have led them to engage in thinking
errors and the resulting problem behaviors.
Behaviorism
It probably doesn’t occur to you to actually teach your clients behaviorism—though
we often use it in our interventions, rarely do we actually discuss the concept with
our clients. This may be especially true for adolescents, as at first, it may be a difficult
concept to understand. However, by teaching adolescents and their parents these con-
cepts, we empower them to analyze their own behaviors and interactions, and make
changes to decrease problem behaviors. It can also be helpful because many adults
and adolescents are very familiar with one aspect of behaviorism—punishment. How-
ever, one of the things I really like about the discussion of behaviorism in Walking the
Middle Path is how much they emphasize the importance of reinforcement—which is
an aspect of behaviorism we often overlook. Parents may get into the habit of imple-
menting punishment without considering how much more effective reinforcement can
be, and because of this, making sure that both the adolescent and parents understand
reinforcement can be extremely helpful in reducing and eliminating problem behaviors
(Miller et al., 2007). See Handout 4.14 for a handout on changing behaviors.
SAMPLE GROUP SESSION FORMATS

In many of the chapters in this book, we have included a sample group session for-
mat for all five DBT modules for adolescents. See Handouts 4.15 and 4.16 for sample
46
Outpatient Settings
handouts that review the group process and group rules. See Table 4.2 for the stan-
dard version of this—in many chapters this format remains the same; however, we
have included adapted and new skills as applicable for the population we discuss in
that chapter. The format below is structured for six weeks in each module. This can be
altered easily, and you will notice different formats in the chapter on DBT with fam-
ilies, in schools, and in a partial hospital setting. Typically, DBT skills groups are open
at the beginning of each module, and then closed until the next module commences.
Table 4.2 Sample Skills Training Schedule
Module/Session Skills, Activities, and Handouts
Mindfulness: Module 1
Session 1 Orientation to DBT and Skills Training
Group Rules
Biosocial Theory
Session 2 Reasonable, Emotion, and Wise Mind
Mindfulness Practice—What Is Mindfulness?
Session 3 Mindfulness What Skills (Observe, Describe, Participate)
Session 4 Mindfulness How Skills (One-Mindfully Effectively,
Nonjudgmentally)
Session 5 Loving Kindness
Session 6 Review
Distress Tolerance: Module 2
Session 1 Review of Group Rules and DBT Skills Training, the Biosocial
Theory, and Emotion Dysregulation
Introduction to Distress Tolerance
Session 2 STOP Skill
Session 3 Distract With Wise Mind ACCEPTS, Self Soothe With the Six
Senses
Session 4 IMPROVE the Moment
Session 5 Pros and Cons, TIPP
Session 6 Acceptance Skills, Willingness, and Willfulness
Walking the Middle Path: Module 3
Theory, and Emotion Dysregulation as needed
Introduction to the Walking the Middle Path Module
Session 2 Dialectics
Session 3 Dialectical Dilemmas
(Continued )
47
Table 4.2 (Continued)

Session 4 Validation
Session 5 Behaviorism
Session 6 Problem-Solving and Behavior Chain Analysis
Emotion Regulation: Module 4
Introduction to Emotion Regulation
Session 2 ABC—Accumulating positive experiences, Build mastery, Cope
ahead
Session 3 PLEASE—treat Physical illness, balance Eating, Avoid drugs,
balance Sleep, get Exercise
Session 4 Mindfulness of Current Emotions
Session 5 Check the Facts
Session 6 Opposite Action
Interpersonal Effectiveness: Module 5
Introduction to Interpersonal Effectiveness
Session 2 GIVE—Gentle, Interested, Validate, Easy manner
Session 3 DEAR MAN—Describe, Express, Assert, Reinforce, be Mindful,
Appear confident, Negotiate
Session 4 FAST—be Fair, no Apologies, Stick to values, be Truthful
Session 5 Factors to consider when asking for something or saying no
Session 6 THINK—Think, Have empathy, Interpretations, Notice, Kindness
OUTCOME EVALUATION
As we mentioned briefly in Chapter 2, outcome evaluation is an important facet of
implementing a DBT program. We have included a few common methods of measur-
ing outcomes in DBT programs here, and then will include any specific assessments
for adaptations in the corresponding chapters.
Diary Cards
As we mentioned earlier in this chapter, diary cards are a versatile tool to measure
progress. Not only can you use it to check in with your clients weekly, but you can
also use it to monitor the frequency of skills use and problem behaviors to see if there
48
Outpatient Settings
are any changes over time. You could also aggregate this data across clients, to see if
there are any overall trends in frequency of skills use and problem behaviors.
The Difficulties in Emotional Regulation Scale (DERS)

The DERS (Gratz & Roemer, 2004) is very common in DBT outcome research and was
developed specifically to measure emotion regulation. It includes six scales: non-ac-
ceptance of emotions, difficulties engaging in goal directive behavior, impulse control
difficulties, lack of emotional awareness, limited access to emotion regulation strate-
gies, and lack of emotional clarity. The DERS is a flexible tool and can be administered
frequently, as it only has 36 Likert-scale items and therefore your clients should be
able to complete it relatively quickly.
The DBT Ways of Coping Checklist (WCCL)

The WCCL (Neacsiu, Rizvi, Vitaliano, Lynch, & Linehan, 2010) is another very common
formal assessment in DBT, and includes scales on skills use, general dysfunctional
coping, and blaming others. Clients are asked to rate skills use on 59 Likert-scaled
items. The WCCL is also an instrument that you could administer to your clients fre-
quently—however, it is longer than the DERS and therefore may take the client a little
bit longer to complete.
CHALLENGES AND SOLUTIONS IN OUTPATIENT DBT COUNSELING
Attrition
One of the benefits of DBT is that clients who engage in a DBT program are usually
less likely to drop out than clients receiving other services at the same site (Ben-Porath
et al., 2004). Regardless, dropout is still a concern, but working with parents and ado-
lescents to commit them both to treatment in the beginning can help combat this. As
we discussed in Chapter 2, this can be difficult, especially when parents are reluctant
to participate. One of the ways to get clients to commit to treatment is to offer a
shorter treatment length (also, see commitment strategies in Chapter 2). You’ll notice
the sample format we have includes six-week modules. You may decide to have lon-
ger or shorter modules—this will depend on how long you believe is reasonable for
the adolescents and parents with whom you will be working. Another approach that
may work in a community mental health center is presenting DBT as a program that
is difficult to qualify for, with only certain clients being included in treatment (Fruzzetti
et al., 2007). Clients may then be more invested in the treatment and feel good about
being part of something special. Recommitment to treatment is essential at times,
and commitment strategies can be revisited as necessary to prevent attrition. Usually,
clinicians set up a certain number of sessions the client can miss before being consid-
ered “on a break” or “on a vacation” from treatment. (Remember, clients can’t fail
49
DBT treatment.) Again, you will want to make this decision based on what you think
is appropriate for you and your clients.
Staff Turnover
Some researchers have found that engaging in DBT training can actually reduce
levels of burnout. Therefore, by teaching clinicians DBT you may be able to reduce
the amount of staff turnover your agency normally experiences (Carmel, Fruzzetti, &
Rose, 2014). Regardless, especially if you work in a community mental health center,
you may experience a fair amount of turnover, and this may be challenging with
regard to maintaining an acceptable level of training in consultation team members.
New staff members can be trained by the team leader, or other team members who
have had an extensive amount of DBT training and experience. You may also wish to
send new staff members to training. For example, Behavioral Tech offers a one-week
intensive training for new team members who are joining teams that have already
attended the DBT intensive training (see Chapter 2 for more about training in DBT).
Treatment Fidelity
In addition to training, you will also need to pay attention to treatment fidelity—you
will want to find a way to measure how much your program adheres to the DBT
model on a regular basis. The easiest way to do this is through the consultation
team—you can have team members listen to or watch tapes of each other, in order
to ascertain that they are adhering to DBT practices. This can include using dialectical
strategies and a behavioral approach to treatment targets. By doing this, you will not
only maintain the quality of your program, but also be sure that you are delivering the
best treatment possible for your clients.
Billing
Billing may be an issue as insurance companies rarely reimburse for all modes of DBT.
There are many ways to approach payment. For example, some experts have posited
that clinicians apply a flat DBT treatment rate that would be billed weekly, regard-
less of the number of sessions or between-session phone coaching (Comtois, Koons,
Kim, Manning, Bellows, & Dimeff, 2007). The authors also suggested that clinicians
could bill insurance for individual sessions, and have the client pay out of pocket for
the cheaper, group sessions. This could also be applicable if you wish to implement
a family-members-only skills group, which can be offered at the same time as the
adolescent skills group. This group could be an out-of-pocket expense for parents,
but at very low cost. Other clinicians have actually measured treatment outcomes and
then provided that data to insurers. By doing this, as well as meeting with insurers to
discuss the importance of maintaining the fidelity of the treatment, they were able
to receive increased compensation for the services they provided (Koons, O’Rourke,
Carter, & Erhardt, 2013). That being said, many clinicians do not take insurance, and
50
Outpatient Settings
another option is to simply bill the client and let them submit to their insurance for
out-of-network reimbursement.
SUMMARY AND CONCLUSIONS

The take away from this chapter is that DBT is very flexible and versatile. Feel free to
be intentionally creative in how you implement modes of treatment, and how you
teach different skills to your clients. There can be a lot of factors to consider, and
some of your main problems may be related to the logistics of billing, administration,
and implementation. Though we don’t include all of the skills in our discussion here
(or even in the text) our hope is that the skills we have highlighted and adapted will
be helpful for your DBT program.
REFERENCES
Ben-Porath, D. D., Peterson, G. A., & Smee, J. (2004). Treatment of individuals with borderline
personality disorder using dialectical behavior therapy in a community mental health set-
ting: Clinical application and a preliminary investigation. Cognitive and Behavioral Practice,
11(4), 424–434. doi:10.1016/S1077–7229(04)80059–2
Carmel, A., Fruzzetti, A. E., & Rose, M. L. (2014). Dialectical behavior therapy training to
reduce clinical burnout in a public behavioral health system. Community Mental Health
Journal, 50(1), 25–30. doi:10.1007/s10597-013-9679-2
Carmel, A., Rose, M. L., & Fruzzetti, A. E. (2014). Barriers and solutions to implementing
dialectical behavior therapy in a public behavioral health system. Administration and Pol-
icy in Mental Health and Mental Health Services Research, 41(5), 608–614. doi:10.1007/
s10488-013-0504-6
Comtois, K. A., Koons, C. R., Kim, S. A., Manning, S. Y., Bellows, E., & Dimeff, L. A. (2007).
Implementing standard dialectical behavior therapy in an outpatient setting. In L. A.
Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications
across disorders and settings (pp. 37–68). New York, NY: Guilford Press.
Fruzzetti, A. E., Santisteban, D. A., & Hoffman, P. D. (2007). Dialectical behavior therapy with
families. In L. A. Dimeff, K. Koerner (Eds.), Dialectical behavior therapy in clinical practice:
Applications across disorders and settings (pp. 222–244). New York, NY: Guilford Press.
Gratz, K. L. & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dys-
regulation: Development, factor structure, and initial validation of the difficulties in emo-
tion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26, 41–54.
Koons, C. R., O’Rourke, B., Carter, B., & Erhardt, E. B. (2013). Negotiating for improved reim-
bursement for dialectical behavior therapy: A successful project. Cognitive and Behavioral
Practice, 20(3), 314–324. doi:10.1016/j.cbpra.2013.01.003
MacPherson, H. A., Cheavens, J. S., & Fristad, M. A. (2013). Dialectical behavior therapy for
adolescents: Theory, treatment adaptations, and empirical outcomes. Clinical Child and
Family Psychology Review, 16(1), 59–80. doi:10.1007/s10567-012-0126-7
51
Neacsiu, A., Rizvi, S., Vitaliano, P., Lynch, T., & Linehan, M. M. (2010). The dialectical behavior
therapy ways of coping checklist: Development and psychometric properties. Journal of
Clinical Psychology, 66, 1–20. doi:10.1002/jclp.20685
Press.
52
5
Family Counseling
Although traditional DBT for adolescents includes a mode of treatment that involves
family members, other researchers have focused specifically on adapting DBT skills
to treat the whole family (Fruzzetti, Santisteban, & Hoffman, 2007). This approach is
logical—if you remember, one of the major facets of the biosocial theory of emotion
dysregulation is the invalidating environment (see Chapter 1). However, in family DBT
counseling, family members are not blamed for contributing to the invalidating envi-
ronment. Instead, the focus is on the system, and the idea that in the face of a fam-
ily member who experiences emotion dysregulation, and subsequently engages in
impulsive or life-threatening behaviors, family members may unknowingly respond in
an invalidating manner, in an effort to cope with the distress those behaviors put on
the system (Miller, Glinksi, Woodeberry, Mitchell, & Indik, 2002). Though this adapta-
tion is still being developed and studied, preliminary studies have shown that treating
the family in skills group is related to a decrease in problem behaviors in adolescents
(Uliaszek, Wilson, Mayberry, Cox, & Maslar, 2014).
CONSIDERATIONS FOR IMPLEMENTING DBT FOR FAMILIES

Family counseling can be implemented in several ways, and you will need to decide
ahead of time what will work best for you and your clients. See Table 5.1 for a list
of different ways to incorporate family counseling with DBT. Your foremost consid-
eration will be the purpose of the intervention and your treatment goals. In general,
implementing skills training via group format is easier and cheaper than working with
each family individually. Multifamily groups that include several clients and their par-
ents are useful if the goal is to facilitate the client’s generalization of skills and stop
problem behaviors (Fruzzetti et al., 2007). Hoffman, Fruzzetti, and Swenson (1999)
also report that by using multifamily groups, group members experience cross-vali-
dation from other group members, see behaviors modeled by others, and experience
dialectics. However, if the treatment goal is to assist the parents and increase par-
enting skills, you may instead wish to have the family members engage in a group
separate from the adolescent. If you decide against implementing skills groups with
the inclusion of family members, you can always implement family counseling on an
as-needed basis, and engage in family sessions when there are specific issues that
need to be addressed. In any of these scenarios, you might consider whether family
53
Table 5.1 Options for Implementing Family Counseling in DBT
Format Benefits
Multifamily skills groups that include Help adolescent generalize skills, stop problem
several families and adolescents behaviors. Group members can validate each
other, model skills use, and experience the
dialectic of different viewpoints.
Skills teaching sessions for just the Can spend more time on problem-solving in a
adolescent and his or her family personalized approach for the family.
Separate skills groups for families and Can focus on skills acquisition for parents
adolescents that run concurrently specifically, including skills related to discipline
and parenting.
Adjunct family counseling sessions that Less involvement of family members may
include the client as needed increase commitment by family members; this
amount may be sufficient.
Adjunct family counseling sessions that Intermittent skills training for parents can
do not include the client as needed address specific problem behaviors in the
system and/or inadvertent validation of
problem behaviors.
members other than parents or guardians should be a part of the groups (e.g., sib-
lings, grandparents). Fruzzetti et al. (2007) emphasize that no matter what format
you decide to implement family counseling, it is important that the counseling envi-
ronment be a no-blame zone, in which both parents and adolescents can feel safe
and work together to increase skills and focus on treatment goals.
ADAPTATIONS TO TREATMENT TARGETS IN FAMILY COUNSELING

If you decide to adapt DBT skills to address the family specifically, Miller et al. (2002)
addressed how treatment targets can be changed accordingly. See Table 5.2 for a list of
these treatment targets and some examples of what the problem behaviors might look
like. Basically, the treatment targets change from the traditional individual hierarchical
targets, and instead are focused on the family system, and problems that involve all fam-
ily members. These treatment targets will not replace the individual treatment targets,
and instead will support the treatment targets developed with the adolescent individually.
SKILLS ADAPTATIONS IN FAMILY COUNSELING

A few researchers have developed a family counseling curriculum that includes
adaptations to DBT skills, as well as some new skills to enhance communication and
54
Family Counseling
Table 5.2 Treatment Targets in DBT Family Interventions

Family Interactions That Contribute Validation and/or reinforcement of life-
to Adolescent Life-Threatening threatening behaviors
Behaviors Invalidation and/or punishment of healthy skills
use
Family/Parent Therapy-Interfering Not providing transportation to treatment
Behaviors Not attending treatment
Not completing family homework assignments
Not seeking out intersession phone coaching
when needed
Family/Parent Quality-of-Life- Being punitive
Interfering Behaviors Being willful
Increasing Behavioral Skills of All Relationship Mindfulness
Family Members Walking the Middle Path
Validation
Problem-Solving
Parenting Skills
Psychoeducation
Dialectical Dilemmas— Parents allowing the adolescent to not return
Excessive Leniency vs. Authoritarian home several nights of the week, then suddenly
Control grounding the adolescent for six months
Normalizing Pathological Behaviors Vacillating between treating harmful and
vs. Pathologizing Normative extreme behaviors as normal, and typical
Behaviors adolescent developmental behaviors as
pathological
Forcing Autonomy vs. Fostering Expecting the adolescent to be able to care
Dependence for him or herself vs. doing too much for the
adolescent
cohesion (Fruzzetti et al., 2007). The format developed by Fruzzetti (1997), which
is for a multifamily skills group, takes place weekly for one and a half hours, for six
months (this can be adjusted as needed). The first hour is used for learning new
skills, and the last 30 minutes is allotted for consultation regarding family interac-
tions and problem-solving, with an emphasis on validation and behaviorism in a sys-
tems approach (Fruzzetti et al., 2007). Hoffman et al. (1999) delineated four basic
55
assumptions in DBT family counseling, which are adaptions from Linehan’s (1993, p. 7)
original assumptions in DBT:
1. There is no one truth nor any absolute truth.

2. Everyone is doing the best he or she can.
3. Everyone needs to try harder.
4. Everyone needs to (try to) interpret things in a mindful/nonjudgmental way.
The following skills have been adapted for use specifically with families in DBT.
Though only a few are highlighted here, the majority of the skills taught in DBT can
be adjusted to address family relationships—this can be as easy as changing the
examples you use in session to make them applicable for family members, and high-
lighting how use of individual skills benefits everyone in the family.
Genograms
Though using a genogram may seem cliché, Miller et al. (2002) actually suggest
using it as a form of assessment when you begin working with a family. The focus
during this activity is on the system, and the pattern of invalidating behaviors in the
family system (for example, if the parents experienced invalidation as children). This
also helps the family see the adolescent’s behavior in the context of the system, and
enhances the no-blame stance in DBT family therapy. See Handout 5.1 for a work-
sheet on using genograms with families in DBT.
Psychoeducation on Relevant Diagnoses

One aspect researchers have suggested is educating family members on mental illness
and emotion dysregulation (Fruzzetti et al., 2007). Psychoeducation may be especially
helpful for parents and family members who do not understand the cause of emo-
tion dysregulation, the function of the behaviors the adolescent engages in, and/or
how they relate to his or her symptoms. This can also include educating parents on
adolescent development, and specifically how they learn how to regulate emotions.
Relationship Mindfulness
Fruzzetti (2006) took all of the skills in the mindfulness module (observe, describe,
participate, one-mindfully, effectively, and nonjudgmentally) and applied them spe-
cifically to focusing on others and relationships. See Handout 5.2 for a related home-
work sheet on using relational mindfulness skills. Relationship mindfulness is based
on specifically being aware of relationships and other people. Not only does this help
increase emotional intelligence, but also it can facilitate the ability of the adolescents
and their family members in validating each other and reducing conflict. Fruzzetti
et al. (2007) also highlight the importance of families spending time together engag-
ing in interactive activities. By assigning this as homework, you can help parents and
56
Family Counseling
adolescents recognize the difference between simply spending time together (e.g.,
watching TV together but focusing on other things) and actually interacting by play-
ing a game, talking, or sitting down for a meal.
Problem Management and Validation

This module doesn’t vary much from the Walking the Middle Path, so we won’t spend
a lot of time discussing it here (see Chapter 4 to read more about the Walking the
Middle Path module). However, Fruzzetti et al. (2007) did create a really neat double
chain analysis for parents and adolescents to work on together to gain understand-
ing into conflict. See Handout 5.3 for an adapted worksheet. Basically, each person
shares his or her initial thoughts and emotions, and then discusses their interacting
responses, thoughts, and emotions that took place during the conflict. This helps
them not only have empathy and validate each other, but to problem solve to prevent
conflict in the future. Teaching parents and adolescents how to reinforce each other
will also help decrease maladaptive behaviors on both sides.
Miller et al. (2002) also encourage the development of a family crisis plan after
engaging in the chain analysis. This plan will be clear on what each family member
needs to do in the case of the adolescent thinking about or engaging in life-threat-
ening behaviors. This is especially important because often in crisis situations, parents
(and adolescents) automatically revert back to previous behaviors without even think-
ing about it. By clearly writing out a plan, family members will be more likely to use
the skills they have learned to reduce life-threatening behaviors.
Radical Acceptance in Relationships

Fruzzetti (1997) adapted the distress tolerance skill radical acceptance to fit the needs
of families who regularly find themselves in the same pattern of conflicts. This skill
is also referred to as closeness, because the goal is to help the parent and adoles-
cent build connection. He delineates three steps: first, the client (or parent) must
stop trying to change the other person, and instead accept any disappointment or
sadness via the use of mindful tolerance. He or she can then grieve the loss of not
being able to change the other individual. The second step is to look at the negative
consequences that were related to trying to change the other person. These can be
personal consequences, consequences for the relationship, and consequences for the
other individual. The final step is to participate fully in the relationship, accepting the
other person as he or she is, and letting go of anger and disappointment through
validation and empathy.
This skill may be difficult to grasp for parents and adolescents. Your job will be to
help them see the difference between behaviors (especially harmful ones, that really
do need to stop) and personality traits. For example, if an adolescent tends to be
forgetful (personality trait) and as result frequently forgets to check in with his par-
ents when he is out with friends (problem behavior), the focus should be on radically
accepting the fact that the adolescent is forgetful. By accepting this, it will be easier
57
for the parent to validate the adolescent, and then they can work together to stop
the problem behavior (acceptance in the context of change!).
Emotion Regulation in Relationships

The focus of emotion regulation in family counseling is to help all family members
be aware of their emotions, and specifically use skills to lower emotional reactivity
during conflict. Fruzzetti et al. (2007) also focuses on teaching family members the
difference between primary and secondary emotions, and how this can affect their
thinking and their behavior during a conflict.
Making Repairs
Fruzzetti (1997) highlights this skill briefly in the interpersonal effectiveness module he
developed for families. What I like about this skill is the focus on the meaning and pur-
pose of an apology. We have become so accustomed to saying the words “I’m sorry,”
that we often forget that the goal of an apology is to acknowledge wrongdoing and
repair the relationship. By focusing on this skill, parents and adolescents can be more
intentional in their apologies, which can increase communication and decrease con-
flict. I personally have primarily used the making repairs skill in groups—for example, if
clients were late, they would make repairs with the other members. They would state
what they were making repairs for (being late) and communicate why they needed
to make repairs (e.g., disruptive and disrespectful to others to be late to group) and
then state what they will do to make sure it will not happen again (e.g., set an alarm
to be sure to leave home on time. If it became a continued problem, they would be
prompted to complete a behavior chain related to the problem behavior of being late
repeatedly). This can be a helpful exercise for parents and adolescents to practice, and
it is also an important skill for the clinician to model when necessary.
Family Diary Card

Just like individual DBT skills training, family members can complete a weekly family
diary card to keep track of skills use and problem behaviors that occur within the
system. This diary card should be personalized to each family, and all family members
should commit to completing the diary card daily (if the adolescent is also engaged in
individual skills training, this diary card will be in addition to the individual diary card
he or she completes weekly). By keeping track of the skills they use and the problem
behaviors that arise, they will be able to acknowledge any positive or negative behav-
ioral patterns, and work to make changes accordingly.
Parenting
Some researchers have developed a whole module based on parenting skills (Fruz-
zetti et al., 2007). This module may be especially helpful if you plan on implementing
58
Family Counseling
parents-only skills groups. The skills taught include validation and problem-solving,
education about developmental stages of adolescents, setting boundaries, and inter-
personal effectiveness skills tailored to parenting. Relational mindfulness and radical
acceptance in relationships can also be interwoven in this module (Fruzzetti et al.,
2007).
SAMPLE FAMILY SKILLS GROUP FORMAT

In Table 5.3 we have developed a sample format for a six-week multifamily DBT skills
group based on the adaptations we described above. Though the structure and con-
tent of each session can definitely be changed to fit the needs of your setting, you
will want to be sure to describe each skill in detail, give a lot of examples, and elicit
questions from group members. You will also want to emphasize the importance
of completion of the family diary card and homework assignments to increase their
mastery of the skills.
Table 5.3 Sample Format of Multifamily Skills Group (Six Weeks)
Session 1 Introduction
Group Rules
Biosocial Theory
Overview of DBT
Psychoeducation on Adolescent Development and Relevant Diagnoses
Review and assign family diary card
Session 2 Review family diary card
Validation of Self and Others
Problem Management
Crisis Planning
Identifying Family Problem Behaviors/Interactions
Assign homework
Relational Mindfulness
Awareness of Others, Interactive Time Together
Assign homework
Emotion Regulation/Decreasing Emotional Reactivity
Assign homework
Interpersonal Effectiveness—Radical Acceptance in Relationships
Making Repairs
Assign homework
Conclusions, Review, Problem-Solving, and Planning
59
CHALLENGES AND SOLUTIONS IN DBT WITH FAMILIES

Unsurprisingly, commitment to treatment is a focal point in working with families in
DBT. In Chapter 2 we emphasized the importance of committing adolescents and
parents to treatment, regardless of family involvement in actual sessions. However, in
family DBT skills training it is essential that all family members are aware of the goals
and purpose of the treatment, and make a decision to engage in treatment. This may
take some time (refer back to the commitment strategies discussed in Chapter 2). In
addition to using DBT commitment strategies, you can nonjudgmentally educate par-
ents on the biosocial theory and how their involvement in treatment can be essential
in helping the adolescent learn healthy coping skills.
As with any counseling intervention for families, when several individuals are
involved, treatment can get more complicated. You may find it more difficult to man-
age the session, especially when there is a high level of emotion dysregulation and
conflict in the family. Your best defense against problems in session is setting the
structure and rules beforehand, and enforcing them when necessary by reminding
participants of their previous commitments. In addition, use the support of the con-
sultation team when needed, and practice radical acceptance and a nonjudgmental
stance, not only of your clients, but yourself.
OUTCOME EVALUATION
Along with the traditional assessments used to measure progress in DBT (see Chap-
ter 2) and other assessments listed throughout this text, you may have treatment
targets related specifically to family relationships that you wish to measure. Consider
the goals of your program, as well as the cost and length of the assessment when
choosing any form of formalized evaluation for families.
Diary Cards and Frequency of Problem Behaviors

As we’ve mentioned, this is the easiest way to measure progress in DBT. By monitor-
ing family diary cards, you have the ability to track use of skills, and problem behav-
iors. Analyzing the adolescent’s individual diary card in addition to the family diary
card can give you a full picture, and can help you connect patterns between the two.
If you aggregate this data over time, you will be able to measure the overall effective-
ness of your program in reducing problem behaviors.
Validating and Invalidating Behaviors Coding Scale

This scale was developed by Fruzzetti (2001) and is actually a coding manual that
you can use to observe parents and rate their behaviors as validating or invalidating
on a seven-point scale. Though more research is needed to validate this scale fur-
ther (it was originally developed and validated for couples), preliminary research did
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Family Counseling
show high inter-rater reliability when observing parent behaviors in a clinical setting
(Shenk & Fruzzetti, 2014). Though this assessment is easily administered, as it can be
done simply through observation, it is possible that the rater could be biased, and
since the ratings are subjective, it may be helpful to have a blind reviewer conduct the
observation and coding.
Adolescent Family Life Satisfaction Index

This 13-item questionnaire measures how positively adolescents rate their families.
The adolescents respond to items on a Likert scale and rate their satisfaction with
interactions with their parents and their siblings (Henry & Plunkett, 1995). Rizvi, Mon-
roe-DeVita, and Dimeff (2007) suggest the use of the scale because it is short, and
easy for adolescents to complete. It can also be administered as frequently as every
session, so you can gain an accurate picture of your client’s progress (Rizvi et al.,
2007).
Family Adaptability and Cohesion Evaluation Scale (FACES) IV

This assessment is by far the most popular and most validated of the assessments
listed here (though, as a result, it will likely be more expensive to administer than the
others). It can be completed by any family member, and includes 42 Likert-scale items
(Olson, 2011). This scale was developed to measure family flexibility and cohesion,
which may or may not be an outcome you are aiming for in your program. How-
ever, the use of DBT skills, including validation and coping, is likely to be related to a
family’s cohesiveness and flexibility. There is an extensive amount of research on the
development of this assessment, which may be a very good reason to choose this
assessment on its own, or along with other tests.
KEY POINTS TO CONSIDER/CONCLUSIONS

The amount you are able to involve family members in treatment may vary based on
your setting and the population with which you work. Regardless, remember that
DBT is extremely flexible, and you can use a lot of different methods to incorporate
the family in skills acquisition. You will also want to emphasize the no-blame stance
in session, and remain nonjudgmental to facilitate family members’ ability to work
together to identify problem behaviors in the system, and most importantly identify
solutions for all of them to live a life worth living (Linehan, 1993).
REFERENCES
Fruzzetti, A. E. (1997). Family DBT skills. Reno: University of Nevada.
Fruzzetti, A. E. (2001). Validating and invalidating behaviors coding scale. Reno: University of
Nevada.
61
Fruzzetti, A. E. (2006). The high conflict couple: A dialectical behavior therapy guide to finding
peace, intimacy, and validation. Oakland, CA: New Harbinger.
Fruzzetti, A. E., Santisteban, D. A., & Hoffman, P. D. (2007). Dialectical behavior therapy with
families. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice:
Henry, C. S. & Plunkett, S. W. (1995). Validation of the adolescent family life satisfaction index:
An update. Psychological Reports, 76, 672–674. doi:10.2466/pr0.1995.76.2.672
Hoffman, P. D., Fruzzetti, A. E., & Swenson, C. R. (1999). Dialectical behavior therapy—family
skills training. Family Process, 38, 399–414. doi:10.1111/j.1545–5300.1999.00399.x
Miller, A. L., Glinski, J., Woodberry, K. A., Mitchell, A. G., & Indik, J. (2002). Family therapy and
dialectical behavior therapy with adolescents: Part I: Proposing a clinical synthesis. Ameri-
can Journal of Psychotherapy, 56(4), 568–584.
Olson, D. (2011). FACES IV and the circumplex model: Validation study. Journal of Marital And
Family Therapy, 37(1), 64–80. doi:10.1111/j.1752–0606.2009.00175.x
Rizvi, S. L., Monroe-DeVita, M., & Dimeff, L. A. (2007). Evaluating your dialectical behavior
therapy program. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical
practice: Applications across disorders and settings (pp. 326–350). New York, NY: Guilford
Press.
Shenk, C. E. & Fruzzetti, A. E. (2014). Parental validating and invalidating responses and
adolescent psychological functioning: An observational study. The Family Journal, 22(1),
43–48. doi:10.1177/1066480713490900
Uliaszek, A. A., Wilson, S., Mayberry, M., Cox, K., & Maslar, M. (2014). A pilot interven-
tion of multifamily dialectical behavior group therapy in a treatment-seeking adolescent
population: Effects on teens and their family members. The Family Journal, 22, 206–215.
doi:10.1177/1066480713513554
62
6
Partial Hospital Programs and Settings
Garry S. Del Conte
This chapter describes the application of dialectical behavior therapy (DBT) for adoles-
cents in a partial hospital program (PHP) setting. This approach has shown promise as
an alternative to hospitalization in treating a transdiagnostic group of adolescents with
severe emotional health problems (Del Conte, Lenz, & Hollenbaugh, 2016; Lenz & Del
Conte, 2016; Lenz, Del Conte, Hollenbaugh, & Callender, 2016). I will review the
advantages of partial hospitalization programs as an alternative to inpatient care,
and provide an overview of milieu treatment incorporating a dialectical philosophy.
I will also describe Daybreak Treatment Center, a clinician-run PHP where I serve as
the clinical director, as an example of one such program, and provide a detailed
picture to help you finesse existing programs or to build new ones. Handouts 6.1–6.9
include sample worksheets helpful for program implementation.
A 2015 report indicated that hospitalization rates had increased 79.45% for 10-
to 14-year-olds and 54.8% for 15- to 17-year-olds between 2006 and 2011 (Torio,
Encinosa, Berdahl, McCormick, & Simpson, 2015). The authors also reported dispro-
portionate increases in the number of hospitalizations for suicide attempt, suicidal
ideation, and non-suicidal self-injury of 151% for 10- to 14-year-olds and 81.6% for
15- to 17-year-olds, trends that the authors characterized as alarming. When pre-
sented with a young patient with a severe mental health disorder, particularly if suicidal
ideation or self-injury is present, a community-based clinician would understandably
recommend hospitalization in the absence of readily available alternatives. However,
inpatient psychiatric care is expensive and evidence for its long-term effectiveness in
reducing mental health symptoms is lacking (Sheldow et al., 2004). The application
of DBT in a PHP program may represent a clinically promising and cost-sensitive way
to address the needs of adolescent patients.
The American Association for Ambulatory Behavioral Healthcare (AAABH, n.d.)
defines partial hospitalization as
a time-limited, ambulatory, active treatment program that offers therapeutically inten-

sive, coordinated, and structured clinical services within a stable therapeutic milieu.
This modality, or method of treatment, is an alternative to hospitalization and offers
the flexibility to deal with a very wide range of conditions.
(para. 1)
63
Garry S. Del Conte
Many researchers (e.g., Hoge, Davidson, Hill, Turner, & Ameli, 1992; Hoge, David-
son, & Sledge, 1997; Kiser, King, & Lefkovitz, 1999; Kiser & Pruitt, 1991; Luber, 1979)
have described partial hospitalization as having multiple benefits as an alternative to
inpatient hospitalization. These benefits include cost effectiveness, improved treat-
ment acceptability, maintaining the patient in their community, and avoiding the stig-
matization associated with psychiatric hospitalization. Compared with hospitalization,
PHPs are inherently cost effective. For example, a study by Grizenko and Papineau
(1992) showed that 6.6 days of PHP treatment could be provided for the same cost
as only one day of hospitalization. Lower costs have the potential clinical benefit of
increasing treatment duration without increasing overall cost per treatment episode.
Lastly, my 20-plus years of experience in managing a clinician-owned and -oper-
ated private sector partial program demonstrates the viability of a business model for
outpatient providers. Clinician-owned and -administered facilities are cost effective
and facilitate provision of evidenced-based treatment free of the potential impedi-
ments associated with larger institutions.
Dialectical Milieu
Researchers have advanced the application of DBT principles and protocols by bring-
ing a dialectical philosophy to our understanding of milieu functioning. However,
it may be helpful for you to have some background information on the concept of
milieu management. The French word milieu translates to “surroundings,” and in
mental health treatment, it is used to describe the physical and social environment
of patient care in hospital, residential, or partial hospital settings. Gunderson (1979,
1983) defined five therapeutic activities and their associated therapeutic functions
within a milieu, regardless of the underlying theoretical model of care. The specific
treatment functions are containment, support, structure, involvement, and validation
(Gunderson, 1979).
Containment represents safety and encompasses both the physical and interper-
sonal safety of each patient. This includes policies and procedures that govern fire
safety, disaster plans, contraband items, staff response to any crisis that presents a
potential risk of patient injury, and the level of staff supervision and patient movement
in the facility. Support refers to the ability of the staff to foster a feeling of hope in the
patient. Staff members are trained to help patients develop adaptive, growth-oriented
attitudes and behaviors. Nurturance, warmth, and encouragement, together with
compassion and sensitivity are hallmarks of supportive staff actions that encourage
patients’ participation in treatment and improve their self-esteem. The third milieu
treatment function, structure, indicates the degree of choice each patient has in the
program of scheduled activities within the milieu. Structure is defined by the pro-
gram’s schedule, its rules and the associated consequences of breaking them, and the
phases or levels of care that mark movement through the program from admission
64
to discharge. The structure of the program provides the scaffolding for the various
modalities of treatment, and creates a sense of routine that fosters self-management
skills. Involvement encompasses the transactional features of milieu that encourage
patients and family members to value their treatment and membership in the thera-
peutic community, which is defined by the interactions between the patient and staff.
Patients are regarded as partners for achieving positive treatment outcomes, and
treatment staff interacts with patients in a manner that promotes a positive treatment
ethic. Activities of involvement may include community meetings, forms of patient
governance, and team-building exercises. Finally, validation refers to milieu activities
that are individualized to each patient’s unique needs and circumstances. It includes
collaboration on an individual’s plan of care and staff-patient interactions based on
understanding and acceptance of each patient’s personal narrative. The term vali-
dation is used similarly in DBT, but it is not synonymous—in DBT, validation requires
the therapist to identify the inherent truth or wisdom in behaviors, even those that
are maladaptive, and to communicate this understanding to the patient. In contrast
to the DBT meaning, Gunderson (1979) defines validation as a function that is the
end point of therapeutic milieu, and is balanced atop the four preceding functions.
A safe, supportive environment that is appropriately structured and valued results in
personal confirmation, an outcome that Gunderson describes as providing “a greater
capacity for closeness and a more consolidated identity” (1979, p. 332).
In addition, Zeldow (1979) described two divergent models of milieu therapy, the
rational model and the dynamic model. The rational model aligns with Gunderson’s
(1979) functions of containment and structure, and the milieu is understood as the
organizational structure that supports the administration of independent treatment
modalities. The dynamic model aligns with Gunderson’s (1979) functions of support
and involvement, and an emphasis is placed on relationships that both bolster and
facilitate change. In the dynamic model, the milieu is viewed as a modality in its own
right: a super modality that supersedes the others.
Zeldow’s (1979) divergent milieu models and Gunderson’s (1979) milieu therapeutic
functions form a foundation to apply a dialectical philosophy to milieu treatment. The
concept of dialectics defines a worldview that incorporates the following assumptions:
1) all things are connected to all other things, 2) change is the only constant, and 3)
seeming opposites can be integrated to form ever-closer approximations to ever-evolv-
ing truths (see Chapter 2). Discerning the truth that lies on both sides of a polarity
and honoring the value in apparent opposites deepen our understanding of milieu
functioning in a manner that enhances program administration as well as patient care.
Figure 6.1 illustrates the features and structure of a dialectically organized milieu. It
is adapted from Linehan’s (1993) description of therapist skills and characteristics and
from Zeldow’s (1979) distinction of divergent milieu models. Despite polar opposites
being present, the effective dialectical stance balances each dimension and meshes
seeming opposites together. That synthesis gives rise to a new understanding, one
that honors the truth in each pole. The central dialectic of DBT is the continuous
joining of acceptance and change. Linehan (1993, p. 110) states, “DBT represents a
balance between behavioral approaches, which are primarily technologies of change,
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Garry S. Del Conte
Oriented Towards Change
The Modality-Driven Rational Milieu Focused

on Containment and Structure
Unwavering Benevolent
Centeredness Demandingness
Dialectical Synthesis
Focused on Validation
Compassionate
Nurturance
Flexibility
The Therapeutic-Community-Driven Dynamic Milieu Focused

on Support and Involvement
Oriented Towards Acceptance
Figure 6.1 Model of a Dialectical Milieu

Source: Adapted by permission from Linehan (1993) Cognitive-Behavioral Treatment of Borderline
Personality Disorder. New York: Guilford Press.
and humanistic and client-centered approaches, which can be thought of as technol-

ogies of acceptance.”
Nurturance vs. Benevolent Demandingness

Linehan (1993) describes the dialectic of nurturance vs. benevolent demandingness
as an essential characteristic of the DBT therapist, and we find it to be a component
of an effectively operating DBT milieu. For example, consider adolescents who strug-
gle with school refusal, and have failed to respond to outpatient interventions. These
adolescents and their families become extremely distraught in response to require-
ments for mandatory attendance, even when the environment is understood to be
warm and supportive.
From a position of benevolent demandingness, the program views admission
and attendance as all-or-nothing propositions. The program includes contingencies
for attendance, which becomes a prerequisite for obtaining desired outcomes. Via
benevolent demandingness, the program upholds a belief in both patient and family
capabilities, and they are encouraged to weather the emotional storm of an initial
intense extinction burst of problem behaviors. In the beginning, the patient and fam-
ily believe that things are getting worse.
66
The nurturance pole upholds a different attitude and behaviors. Staff members
are predominately sensitive and compassionate. Teaching, coaching, and cheerlead-
ing are used to foster learning how to change and let go of avoidance in favor of
approach and attendance. Unfortunately, in isolation, we have rarely seen either
stance consistently produce the desired results.
Joining a nurturing stance with one of benevolent demandingness has yielded a
protocol that honors both sides of this polarity. Admission is an extended process
that includes partial day attendance, and occurs over a few days, which allows for
both exposure and shaping. During this time, the primary therapist weaves together
psychoeducation and lessons on selected skills and coaches the family and patient to
restructure the home environment to decrease avoidance and increase attendance.
This process unfolds against a backdrop that holds firm on the end point of the
admission process: regular, daily, full-time, and on-time attendance. This synthesis
results in improved treatment efficacy and enhanced treatment acceptability.
Unwavering Centeredness vs. Compassionate Flexibility

The polarity of unwavering centeredness vs. compassionate flexibility is a second
dialectical dimension (Linehan, 1993) used in DBT milieu management. The milieu
reflects unwavering centeredness on a set schedule and reasonable rules. The value
of a consistent schedule and consensus on which behaviors are encouraged (or
discouraged) creates cohesion among the staff, and a predictable, safe setting for
patients and family. However, an overly rigid focus on consistency or rule compli-
ance can restrict the milieu from modeling a synthesis that permits the simultane-
ous expression of compassion and control. In this regard, Linehan states, “Neither
arbitrary boundaries or consistency is particularly valued in DBT” (1993, p. 110). The
capacity to remain open to new information, to modify expectations when necessary,
and to exhibit flexibility without sacrificing control form the blueprint for reaching a
dialectical synthesis.
For example, consider our milieu rule on subgrouping. This rule prohibits communica-
tion between patients outside of regular program hours. This rule is not popular among
adolescent patients because it runs against the grain of normative adolescent experi-
ence. However, without this prohibition, the problems that flow from extra-program
interactions between patients are manifold. The fundamental difficulty is that once a
subgroup is established between two or more patients, their open, honest participation
in key treatment modalities is compromised. Specifically, self-disclosure is diminished,
and the potential for positive peer pressure to reinforce change in problem behavior is
often lost. This rule and the manner in which we describe the benefit to patient and
families have stood the test of time; however, exceptions are occasionally made. Such
exceptions most frequently occur with socially isolated, avoidant patients who reap
a significant therapeutic benefit from post-program hour socialization. The ability to
make exceptions requires remaining open to new and relevant information that leads to
flexible, creative rule modification. A dialectical synthesis of compassion and control is
achieved when exceptions are implemented in a time-limited, adult-supervised manner
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Garry S. Del Conte
with the collaboration of staff, patients, and parents. In sum, effective exceptions are
enhanced by being aware of the polarity, including its dialectical tensions and the need
for solutions that honor the truth on both sides.
Rational vs. Dynamic Milieu Models

The rational milieu is designed to efficiently deliver treatment modalities. Functions of
containment and structure are reflected in milieu features such as a precisely executed
schedule and clear, simple rules. In the PHP setting this model intensifies the treatment
effect, not only by providing for a high treatment dose, but also by encouraging coor-
dination and collaboration among treatment modality providers. Viewing modalities
as independently efficacious also promotes maintaining treatment adherence within
modalities. In this model, the combined effect of modalities is synergistic (Abroms, 1969).
In contrast, the dynamic milieu model is interpersonally driven and based on the
values and principles of therapeutic community movement (Jones, 1983; De Leon,
1994). Functions of support and involvement yield what Silvan, Matzner, and Silva
(1999) term a “super group.” In the super group, patients are a meaningful force
in reaching positive treatment outcomes. Treatment staff models a pro-treatment
ethic and maintains a milieu culture that promotes the assumptions of the underlying
model of care. This approach has particular utility in adolescent treatment because
it incorporates important developmental processes associated with peer group influ-
ence. Prinstein and Dodge (2008) report that the developmental literature consis-
tently supports the strong effect of peer influence among adolescents. Allen and
Antonishak (2008) add that peer group influence can have a powerful and positive
effect on acquiring and transmitting adaptive values. The authors also note that the
experience of helping one another in this context has the added benefit of producing
strong positive feelings and enhancing self-esteem.
We cultivated a hybrid form of milieu group therapy termed problem-solving group
as a means of achieving a dialectical synthesis between the rational, modality-driven
model (with its value on structure and efficient scheduling), and the dynamic model
(with its values on social process, interpersonal connection, and positive peer pres-
sure). The structure and application of this problem-solving group is detailed in the
concluding section of this chapter.
ADAPTATIONS TO DBT FOR PHP SETTINGS—THE DBT MILIEU APPLIED
Treatment Context
Daybreak Treatment Center was founded in 1992 by two health care providers with
past experience in hospital-based child and adolescent mental health care. The
facility is accredited by the Joint Commission and holds state licensure to provide
partial hospitalization treatment and state approval to provide transitional educa-
tional services. The physical plant is a detached one-story structure of approximately
68
Table 6.1 DBT Treatment Assumptions in an Adolescent Partial Hospitalization Program
1. Everyone is doing the best they can.

2. Everyone wants to improve.
3. Everyone wants to do better, try harder, and be more motivated to change.
4. You may not have caused all of your problems, but you still have to solve them.
5. Life is painful as it is currently being lived.
6. New, more skillful behavior must be learned and applied in all important situations.
7. Dialectics means two things that seem like opposites but can both be true.
8. It’s always better to take things as well-meaning instead of assuming the worst.
9. You cannot fail in this therapy.
10. All behaviors (actions, thoughts, and emotions) are caused.
11. Figuring out and changing the causes of behavior are more effective ways to change
than judging and blaming.
Adapted with permission from: Miller et al., 2007.
5,500 square feet located on a one-acre property in a suburb of a large southeast-

ern city.
More than half of the patient care space is available for independent outpatient
mental health services. The interior space is designed to enhance the engagement
of patients, families, and staff in DBT treatment principles and to create an atmo-
sphere infused with the DBT skills curriculum. Artwork throughout the facility is visu-
ally pleasing and conveys a DBT theme, and DBT vocabulary, idioms, and mnemonics
are prominently displayed. Additionally, whiteboards with markers and the list of DBT
treatment assumptions are placed throughout the facility with an open, ongoing
invitation to staff, patients, and families to write and endorse treatment assumptions
they find helpful or appealing (see Table 6.1). Interactive bulletin boards dedicated to
different DBT skill modules serve as an additional engagement and teaching tool and
are included in two classroom spaces and three group rooms. Group rooms also have
audio-visual equipment and whiteboard space available for teaching DBT skills and
for other group modalities.
Patient Characteristics
The adolescent patients range in age from 13 to 18 years. All admissions are volun-
tary, and costs are paid directly by the family or their insurance carrier. The average
length of stay for the most recently completed year (2015) was 31.5 days or just over
six weeks. In a recent sampling (Lenz et al., 2016) of 66 consecutive community-re-
ferred admissions, the majority were Caucasian females, with an average age of 15.
Most patients were diagnosed with depressive disorder, bipolar disorder, or mood
disorder not otherwise specified.
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Garry S. Del Conte
Table 6.2 Curriculum Template for a DBT Partial Hospital Program
Time Monday to Friday
7:45 am Arrival and preparation for morning meeting

8:00 am Morning meeting and goal sheet review
8:30 am Educational therapy and academic preparation
11:00 am Problem-solving group
12:00 am Lunch and community assignments
12:30 am DBT skills group
1:45 pm Closure group and evening/family time goal setting
2:00 pm Dismissal
Morning Meeting and Mindfulness

See Table 6.2 for the typical daily schedule at Daybreak Treatment Center. Morning
meeting occurs daily for 30 minutes and opens the program day. The meeting begins
with each patient reading from the prior evening’s daily goal sheet (Handout 6.1).
The daily goal sheet, which differs from the patient diary card, is a group monitoring
device that provides feedback from self, family, and staff for the previous 24 hours.
Patient self-monitoring includes personal ratings on DBT homework and diary card
completion. Parents provide comments on the previous night’s activity with a focus
on description rather than judgment. The group leader and members use informa-
tion reported from the daily goal sheet to highlight potential agenda items for the
remainder of the days’ scheduled modalities, which could include individual or family
therapy or problem-solving group therapy. This review process thereby strengthens
the pertinence of upcoming modalities with information and collaboration across
providers and modalities. Morning meeting always closes with a brief mindfulness
activity that is chosen by either patients or the staff.
Educational Therapy and Academic Preparation

Educational therapy and academic preparation occur daily and account for 15 hours
a week on average. Every patient is enrolled in a state-approved transitional educa-
tional program and is provided with an individualized course of study that mirrors the
curriculum of the school to which they will return. To maintain therapeutic intensity,
the educational space is adjacent to patient care areas. Educational staff members
use DBT strategies and coach skills in addressing behaviors that manifest in the learn-
ing environment. In addition to teaching self-management skills, the educational spe-
cialist also uses missing-links analysis when homework completion is a target (see
Handout 6.2—Missing Links Assessments).
70
Problem-Solving Group
The problem-solving group meets daily for an hour. The group leader teaches and
guides group members in the use of behavioral assessment (chain and missing-links
analysis) and solution analysis. The group balances social process components (asso-
ciated with the dynamic milieu model) with the structure of a DBT individual session
(associated with the rational, modality-driven milieu model). Group members are
encouraged to invite other members to address problematic behavior revealed during
the morning meeting. Avoidance is addressed through the transparency afforded
by parental report discussed in the morning meeting. Group members also consult
their own diary cards and are expected to bring problematic behaviors to the group
following the targeting hierarchy of stage one DBT (see Chapter 1). For example, if a
patient was absent the prior day and also reported a serious peer conflict related to a
relationship target, the absence, which interferes with therapy, would be addressed
before the peer conflict, which is a quality-of-life issue.
The group, coached by the leader, strives to maintain a dialectical stance, balanc-
ing acceptance and change while collectively completing chain and solution analy-
sis. The members work together on troubleshooting solutions and following up on
agreed solution analysis. Group process elements may include members devising pro-
grammatic contingencies for patients who are willing to collaborate on having their
environment prompt them towards more effective behavior. The group process also
teaches and reinforces skills. Senior group members can experience a sense of mas-
tery and competence by teaching skills to newer members. Teaching skills to others
helps patients see themselves as positive role models and assists in peer maintenance
of a pro-treatment community ethic. The problem-solving group also provides mem-
bers with opportunities to validate one another, to reinforce effective behavior, and
to provide cheerleading as needed.
Lunch and Community Responsibilities

A 30-minute period for lunch and community responsibilities is used strategically to
manage social interactions with assigned seating and to provide the experience of
helping with common family-friendly household tasks. The Lunch Time Tasks work-
sheet (see Handout 6.3) will help you facilitate organizing the lunch period. Lunch-
time is also used as an opportunity for informal practice of mindful eating and to
encourage healthful nutrition with reference to reducing vulnerability as taught in
the PLEASE skill.
DBT Skills Group

The DBT skills group meets daily for 90 minutes. It is staffed with co-leaders and struc-
tured as recommended by Linehan (1993, 2015) and Rathus and Miller (2015). An
initial period focuses on homework review, and after a brief break, new skill(s) and a
subsequent homework assignment are covered.
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Garry S. Del Conte
Homework is assigned daily, and homework tasks have been modified in two
ways. First, worksheets that require weekly reporting now accommodate daily or
weekend-long time frames. Second, patients are routinely assigned the home task of
teaching skills to their parents (Handout 6.4), which has multiple objectives. Teach-
ing skills to parents creates a pro-treatment atmosphere in the home. It reinforces
the adolescent’s learning and allows them to demonstrate skillful behavior in the
presence of their parents. Further, the parents benefit by knowing which skills are
currently being taught and by having the opportunity to learn and practice skillful
means on their own.
Daily skills learning over multiple weeks can become stale and stagnate. To remain
faithful to the content of the published skills curriculums (Linehan, 2015; Rathus &
Miller, 2015), supplemental teaching activities designed to create greater patient
interest and learning through action-oriented individual and group activities have
been added to our schedule of skills (Del Conte & Olsen, 2016).
One important way skills teaching is facilitated is through the use of what Andolfi,
Angelo, Menghi, and Nicholò-Corigliano (1983) described as the concrete metaphor.
The concrete metaphor, created by the therapist (or skills trainers), uses play and a
tangible metaphor to strengthen skill acquisition. For example, one way to reinforce
the lesson of opposite action is to play the game of Sardines, which flips the concept
of classic Hide-and-Seek. In Sardines, one person hides while all other players close
their eyes and count (usually to about 25). When the counting is completed, the
search for the hider begins. When a seeker finds the hider, he or she doesn’t say any-
thing, but in the spirit of opposite action, quietly crawls into the hiding spot with the
hider. The person who finds the hider must wait until no one is nearby before crawling
into the same space to prevent others from finding the spot. In Sardines the seekers
slowly disappear, and the hiding place becomes increasingly cramped as the hiders
become packed in like sardines. The game ends when the last of the seekers finds
the “sardines.” When the participants discuss the game experience, the trainer can
make teaching points about the opposite action skill and make analogies between
the game and their real-life experiences using the skill. This alteration is supported
by results from a recent study in this PHP-based application of DBT, which found that
the adolescent population appears to learn and apply skills more effectively when the
learning includes action and concrete exercises (Lenz et al., 2016).
A final teaching tool is contained in our DBT@Daybreak YouTube channel (www.
youtube.com/channel/UCAVlvlYOig-2OuC9Shc-dlg). This channel includes a collec-
tion of entertaining video clips that teach skills and are organized according to the
lessons that make up our DBT milieu skills curriculum. An example might include
watching the online video the “Sad Cat Diaries,” and discussing common thinking
mistakes (see Handout 6.5—Top 10 Thinking Errors).
Closure Group
The 15-minute closure group activity is the briefest of the program day and often
merges with the end of DBT skills group. Each patient receives their program goal
72
sheet for the program day and briefly interacts with staff regarding their functioning
during the current day and their behavioral objective for the coming evening.
Parent DBT Skills Class

A once weekly group for parents includes the three components of the Middle Path
module (Miller et al., 2006; Rathus & Miller, 2015), and the format is modeled after
that provided by Perepletchikova and colleagues (2011). The content is suitable for a
six-week sequence, and the format allows rotating staff instructors to facilitate sched-
uling (see Table 6.3). The topic listing and handouts are organized as a Skills Manual
for Families, and they are provided at the time of admission and family orientation.
Table 6.3 Curriculum for Six-Week Parent Middle Path Skills
Date Lesson Topic Description
1 Introduction to Guiding principles of dialectics (i.e.,

Dialectical Reasoning and there is no absolute nor relative truth,
Problem-Solving opposite things can both be true,
Dialectics Handout I change is the only constant, and change
is transactional), how these principles
apply to parenting and ways to practice
dialectics.
2 Three Common Dialectical Dialectical dilemmas that apply to
Dilemmas of Adolescence parenting adolescents (excessive
Thinking Mistakes leniency vs. authoritarian control; forcing
Dialectics Handout II autonomy vs. fostering dependence;
and pathologizing normative behaviors
vs. normalizing pathological behaviors).
Reviewing common thinking mistakes
that impact ability to remain dialectical.
3 Mindfulness of Relationships/ Defining validation, why we validate,
Validation roadblocks to validation, ways parents
Five Ways Parents Ignore inadvertently invalidate underlying
Underlying Feelings Handout feelings, important things to validate.
Validation Handout I Defining teen and adolescent stages that
can reduce ability to understand and
relate.
4 Creating a Validating Nonverbal (e.g., active listening and being
Environment mindful of invalidating reactions, such as
Validation Handout II rolling eyes and turning back) and verbal
validation (e.g., observing and reflecting
feelings back without judgment, looking
for kernel of truth).
(Continued )
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Garry S. Del Conte
Date Lesson Topic Description
5 Introduction to Behavior Defining behavior and determining the

Change Techniques functions of the behavior, vulnerability
Behaviorism Handout I factors, replacement behaviors, and
incompatible behaviors.
6 Ways to Increase and Setting behavioral goals, reinforcement,
Decrease Behavior punishment, extinction, and differential
Behaviorism Handout II reinforcement.
TREATMENT ADHERENCE IN THE DBT MILIEU

See Table 6.4 for a list of the modes and treatment team members in the DBT milieu
with corresponding behavioral targets. In addition to addressing treatment targets via
several modes of treatment, we also maintain the treatment fidelity through several
different venues.
Therapist Supervision/Consultation Group

A supervision/consultation group for primary therapists meets weekly for 90 min-
utes and is organized as recommended in the original treatment manual (Linehan,
1993). This group is distinct from traditional team staffing. In a standard team staff
meeting, all treatment team members report on treatment progress and modify
goals and interventions for each patient’s individualized treatment plan. In contrast,
the DBT supervision/consultation group is a provider-centered group required for all
primary therapists and may include therapists providing DBT skills and leading the
problem-solving group. The primary goal of the supervision/consultation group is to
enhance clinician competence and motivation to deliver DBT in a manner consistent
with standard treatment principles (Linehan, 1993) and accepted adaptations appli-
cable to adolescents (Miller et al., 2006).
Monthly Staff Supervision/Consultation Group

A monthly supervision consultation group for all staff members supplements the
ongoing staff training, consultation, and cheerleading that occurs on a nearly daily
basis through constantly unfolding and changing milieu events. This meeting has a
broader scope and more flexible format than the weekly meeting, but it retains a
focus on staff motivation and adherence to the treatment model. An opening mind-
fulness exercise and a review and discussion of one or two commitments from among
the staff and therapist commitments begin these meetings. Activities vary and are
based on staff requests or perceived needs. Activities might include didactic teaching,
role-plays, and problem-solving with challenging cases.
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Table 6.4 Hierarchy of DBT PHP Behavioral Targets by Role and Mode
Mode or Treatment Team Role Behavioral Target Hierarchy
Admission Process P retreatment orientation/commitment of patient and family

Pretreatment assessment of patient goals and problems
Primary Therapist ontinued orientation/commitment of patient and family
C
Overall coordination of modes and behavioral targets
Individual Therapy ecrease life-threatening behaviors
D
Decrease therapy-interfering behaviors
Decrease quality-of-life problems
Increase skill acquisition, application, and generalization
Medication Management E nhance capability to acquire skills
Decrease quality-of-life problems associated with DSM-V
diagnosis (e.g., symptoms of Bipolar Disorder)
Phone Coaching (after E liminate suicide crisis behaviors
program hours) Increase skill application and generalization
Therapy relationship repair
Skills Coaching in the Milieu S top behaviors that destroy therapy
Increase skill application and generalization
Morning Meeting ecrease therapy-interfering behaviors
D
Increase treatment commitment
Increase problem-solving and planning skills
Educational Specialist/ ecrease therapy-interfering behaviors
D
Educational Therapy Decrease academic-related quality-of-life problems
Increase self-management skills
DBT Problem-Solving Group Decrease therapy-interfering behaviors
Increase interpersonal skills
Increase problem-solving and dialectical reasoning skills
Decrease quality-of-life problems
DBT Skills Group S top behaviors that destroy therapy
Increase acquisition and application of DBT skills
Parent Skills Class S trengthen treatment commitment
Increase Middle Path skills acquisition, application, and
generalization
Phases of Care
Features of the milieu structure inspired by DBT principles include a system of treat-
ment phases that honor the principle that DBT is a voluntary process. Patient com-
mitment is required for treatment to be effective. Our phase system is inspired by and
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Garry S. Del Conte
modeled after the phases of treatment for DBT in adult inpatient settings (Swenson,
Witterholt, & Bohus, 2007). Patient movement from admission through treatment
and discharge is marked by the treatment phases of 1) Entering, 2) Working, and 3)
Exiting.
The Entering Phase blends orientation and strengthening commitment with assess-
ment, goal formulation, and the creation of a crisp, behaviorally specific set of tar-
gets related to goal attainment. Handout 6.6 includes an overview of an acronym
to help the adolescents understand treatment (Behavioral, Educational, Action Ori-
ented, Teamwork), and Handout 6.7 is an identification worksheet. Both of these
devices provide a foundation for the work in the Entering phase. New patients and
family members also view a creative and highly informative eight-minute YouTube
video by Esme Shaller titled “What the Heck Is DBT?” (www.dbtcenteroc.com/
what-the-heck-is-dbt-by-dr-esme-shaller-ucsf/).
The first family meeting occurs after the patient has made a commitment to par-
ticipate. The patient has identified personally meaningful goals and commits to using
skillful means in lieu of problem behaviors. In that first family meeting, the patient
presents goals and discusses problem behaviors. The patient is also encouraged to
ask for parental help in carrying out the plan. All standard DBT commitment strat-
egies (see Chapter 2) may be used as needed during this phase. Programmatically,
advancing from Entering to Working is encouraged by contingencies in the milieu,
staff cheerleading, positive peer pressure, and when indicated, problem-solving in the
problem-solving group. These strategies in combination usually keep the time spent
in the Entering Phase under two weeks. A congratulatory group announcement pub-
lically marks movement from the Entering to the Working Phase.
The Working Phase focuses on learning and practicing new skills in all relevant
contexts. Targets in the Working Phase are personalized and, as one would expect
in a transdiagnostic group, specific targets in the quality-of-life domain vary widely
among group members (see Table 6.5). What remains invariant is adherence to the
DBT target hierarchy, which places reduction of life-threatening behaviors before all
other considerations. Also consistent with standard stage one DBT, the second class
of behavioral targets comprises behaviors that interfere with or threaten the ability to
receive or continue in care.
The third phase, Exiting, begins in the last week of PHP treatment and runs con-
currently with the Working Phase. Patients in this final phase are entitled to addi-
tional perks like leading morning meeting mindfulness, assisting with orientation of
new patients, and most popularly, earning the privilege of exchanging accumulated
stickers for cash value gift cards. Contingencies aside, the work of Exiting is to create
patient commitment and involvement in a practical plan of continued care. See Hand-
out 6.8 for a handout on the three phases of treatment.
Parents are always instrumental in supporting a continued care plan, and case
management services are provided to assist with the process. Concurrently, this phase
is implemented to embrace the consultation to the patient focus of DBT. Frequently,
patients are returning to a community therapist who may not be trained in DBT. In
those cases, patients are coached to ask for what they need. The usual request is
76
Table 6.5 Treatment Targets for a DBT PHP

Life-Threatening Behaviors Harm to self or others
Urges to harm self or others
Thoughts of harming self or others
Voicing a desire to harm self or others
Milieu-Interfering Behaviors Being disruptive in group sessions
Not practicing skills or completing diary card
Sleeping in group sessions
Behaviors Risky sex/impulsive behavior
Vandalism
Lying to parents
Breaking rules at home
Academic issues
Skipping school
Distress Tolerance
Emotion Regulation
to continue the features of DBT that are typically compatible with the practice pat-
terns of most outpatient providers. For example, asking to continue with a form for
self-monitoring, retaining behaviorally specific goals, or beginning sessions with a col-
laborative agenda are all reasonable requests. It can also mean that the DBT program
therapist is available to speak to the outpatient provider in support of, not in lieu of,
the patient’s request. The exact manner in which the consultation is implemented
must take into account the patient’s age, his or her capacities to interact with adults
in powerful positions, and the importance of the task to be completed. As a DBT ther-
apist, a good place to start the decision-making process might be with the question,
“Am I robbing this adolescent of the opportunity to become more skillful if I step in
and do this for him or her?”
Behavioral Contingencies and Expectations

If the phases of care provide an overview map of the treatment course from admis-
sion to discharge, then behavioral contingencies and expectations form the specific
directions. Community rules and guidelines are grouped into categories consistent
with DBT concepts of therapy-enhancing, therapy-interfering, and therapy-destroy-
ing behaviors (see Handout 6.9). Contingencies are weighted towards use of positive
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Garry S. Del Conte
reinforcement. For example, patients can earn stickers for educational and DBT skills
homework completion and program points for therapy-enhancing behaviors like
on-time attendance and positive group participation. Points earn levels that translate
into daily and weekly privileges. Aversive consequences apply, but they retain a prob-
lem-solving character. Worksheets termed TIBS (Therapy-Interfering Behavior Solu-
tions) can double as a correction-overcorrection protocol for egregious rule violations.
Worksheet elements consist of a mini chain analysis for acts of commission or, in the
absence of an expected behavior, a mini missing-links assessment. In all cases, staff
members who coach the patient towards more skillful future responses and making
appropriate repairs when indicated oversee these processes.
Staff Use of Validation and Skills Coaching

The treatment staff cultivates a pro-treatment community ethic consistent with the
assumptions and principles of DBT. The staff endeavors to create a skills-savvy atmo-
sphere infused with the language and concepts of the DBT skills curriculum. The staff
is versed in effective coaching including mini chain and solution analysis as needed
throughout the program day. The staff is trained to create a no-fault, validating envi-
ronment that forms the foundation for ongoing pursuit of change, moving the patient
closer to their treatment goals. Staff members’ understanding of validation and its
effective use is important for two reasons. First, validation is generally accepted to be
central to addressing the biological vulnerabilities of individuals who have deficient
emotional modulation and who have been exposed to invalidating experiences in
their families and in the community at large. Second, validation effectively addresses
adolescent developmental vulnerabilities associated with normative tasks of self-defi-
nition and identity formation. A staff that conveys understanding decreases willful-
ness and increases willingness to participate in problem-solving.
TREATMENT TEAM ROLES IN THE DBT MILIEU
Administrator
The administrator is responsible for establishing and implementing a profitable busi-
ness plan consistent with the clinical mission of the program. Administrators are in
charge of all billing and accounts receivable procedures, all negotiations and contracts
with third-party payers, and all policy and procedures related to census management
including public relations, communication, and marketing.
Clinical Director
The clinical director is a Linehan Board-Certified DBT Clinician. The position requires
supervising all aspects of patient care and program implementation. He or she is
responsible for leading all facility staff to provide DBT in accordance to the standards
78
Table 6.6 Daybreak Treatment Center Staff Agreements
1. Dialectical Agreement: No one individual or viewpoint is the “right” one, everyone’s

viewpoint has validity, and the truth is arrived at by integrating differing, even
opposing, points of view.
2. Phenomenological Empathy/Nonpejorative Agreement: Staff members will seek
out the most empathic interpretation of the clients’ and their colleagues’ behavior,
being guided by a nonjudgmental behaviorally descriptive approach to the empirical
evidence.
3. Consistency Agreement: Although different staff members should be consistent in
focusing on each patient’s targets, on observing program rules and policies, and on
implementing DBT principles and guidelines, they need not be consistent in matters of
style or approach.
4. Observing Limits Agreement: Different staff members should honor their own
natural personal limits in the program. These limits will, of course, be different from
one staff member to the next and may differ within staff across time (as long as all
staff members are also observing program-wide limits as articulated in rules and
policies of the program).
5. Fallibility Agreement: All staff members are fallible, make mistakes, and therefore
need not be defensive about this; we agree to use these moments as opportunities to
better learn the treatment model.
6. Consultation-to-the-Patient Agreement: All staff members will consult to the
patient, within the limits of their developmental capabilities, in managing his or her
relationships with others, including family and other staff in the program, rather than
trying to manage those things for the patient.
Adapted with permission from: Swenson, C. R., Witterholt, S., & Bohus, M. (2007). Dialectical behavior
therapy on inpatient units. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical
practice (p. 84). New York, NY: Guilford Press.
under which the empirical base was established. The clinical director is also respon-
sible for modeling adherence to Staff Agreements (Table 6.6) and for being accessi-
ble to consult with all program staff throughout the program day. He or she is also
responsible for all training and research activities occurring in the facility. Lastly the
clinical director is responsible to the administrator to ensure that all services are pro-
vided in a cost-effective manner consistent with organizational budgetary goals and
objectives.
Admissions Director
The admissions director is responsible for completing all pre-admission tasks including
face-to-face assessment to determine appropriateness for admission in accordance
with program admission criteria. The admissions director takes the lead in the initial
orientation of patients and families to program requirements and in strengthening
79
Garry S. Del Conte
their commitment to care. The admission director coordinates with the administrator
and clinical director to manage issues regarding finances or suitability for treatment.
Primary Therapist: Case Management, Individual

Therapy, and Family Meetings
All primary therapists complete foundational training in DBT or are advanced doctoral
students in clinical psychology working under the direct supervision of the clinical
director. The primary therapist is responsible for case formulation and overall coor-
dination of treatment interventions. The primary therapist also provides individual
therapy and family meetings. Sessions are structured in keeping with standard out-
patient DBT (Miller et al., 2006). The Entering phase is the pretreatment stage and
includes orientation to DBT treatment assumptions, use of a daily diary card, and
the role of chain analysis in problem-solving. Most importantly, the primary thera-
pist is responsible for shaping a strong commitment to participate in DBT treatment
that includes reaching a mutual agreement on goals and target problems. From the
point of commitment, individual sessions follow the standard DBT target hierarchy
that sequentially address decreases in 1) life-threatening behavior, 2) therapy-inter-
fering behavior, and 3) quality-of-life-interfering behavior while seeking 4) increases
in use of skills across all needed areas. This latter target is also addressed through DBT
phone coaching after program hours and during weekends.
The family initially attends individual sessions to join in and support the treatment
commitment made by the patient. Subsequent meetings are provided to address
family transactional patterns that are increasing or decreasing problematic behaviors,
to structure the patient’s environment, and to create case management plans for
post-discharge care.
Psychiatrist
A child and adolescent psychiatrist oversees all medical aspects of care. Each patient
is evaluated, and psychotropic medications are used when indicated. Their effective-
ness is monitored and managed by the physician with feedback from other team
members. The psychiatrist operates from a DBT informed standpoint, which means
that medication is prescribed to enable acquisition and use of skills. The physician is
also aware of efforts to treat the patient in the home environment and supportive of
them. When hospitalization is needed, the physician provides attending services and
partners with the primary therapist and family towards a rapid transition back to the
PHP level of care whenever feasible.
Director of Education and Educational Specialist Staff

The director of education provides or supervises educational specialists in providing
educational assessments, interventions, and liaison with each patient’s family and
home school. The educational specialists approach the tasks of education from a DBT
80
informed perspective. In class, use of DBT skills is frequent and specific to behavioral
targets. Missing-links analysis seems particularly effective in increasing task completion
and serving as a useful springboard for teaching self-management skills. Additionally,
educational specialists serve as DBT skills trainers. Professional educators are often a
good fit for teaching the skill modules of DBT and balance nicely with co-leaders who
have a traditional mental health care background. This seemingly nontraditional role
for educators is likely to become more commonplace with the introduction of DBT
teaching materials specifically for educators in school settings (Mazza, Dexter-Mazza,
Miller, Rathus, & Murphy, 2016).
Program Coordinator
The program coordinator is in charge of all milieu policies and procedures and serves
as a facility manager responsible for the integrity of the physical plant. In collabo-
ration with program therapists and the director of education, he or she is responsi-
ble for program implementation in the face of frequently complex and challenging
patient and family presentations. Lastly, he or she is responsible for all staff schedul-
ing, ensuring the efficient use of staff resources, continuously accounting for census
fluctuations and other factors affecting staff availability and staffing needs.
OUTCOME EVALUATION
Whenever treatment is adapted from its original evidenced-based structure we
assume an obligation to collect data to know whether or not we are achieving
effective outcomes. Rizvi, Monroe-De Vita, and Dimeff (2007) provide additional
reasons including gaining ongoing support from administrators, improving reim-
bursement rates with third-party payers, establishing credibility with patients and
families to make a commitment to treatment and providing the treatment staff
with evidence that their efforts are effective. In addition to the Difficulties in Emo-
tion Regulation Scale (DERS; Gratz & Roemer, 2004) and the DBT Ways of Coping
Checklist (WCCL; Neacsiu, Rizvi, Vitaliano, Lynch, & Linehan, 2010) described in
Chapter 4, we have also used the assessments below to evaluate outcomes in our
program.
Interpersonal Sensitivity (INT)

The INT (Derogatis, 1994) is actually a subscale from the Symptom Checklist-90-R
(SCL) that focuses specifically on an individual’s interactions with others and aware-
ness of emotions in relationships. This subscale can be used to measure skills use
related to the interpersonal effectiveness module, as well as the adolescent’s ability
to regulate emotions and manage stressful situations. This assessment can be helpful
in conjunction with other methods of evaluation to gather information specifically on
the adolescent’s relationships.
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Garry S. Del Conte
The Frieburg Mindfulness Inventory (FMI)

The FMI (Walach, Buchheld, Buttenmuller, Kleinnecht, & Schmidt, 2006) is a 14-item
self-report assessment that measures the adolescent’s ability to be aware of the cur-
rent moment. Items are Likert scaled, and questions are framed around the ado-
lescent’s ability to objectively notice emotions and experiences. This assessment is
relatively short, and therefore it can be administered frequently to measure adoles-
cents’ mindfulness skill development.

I have endeavored to integrate theoretical and practical issues to demonstrate how DBT
might be effectively applied in a PHP setting. If the essence of a “good idea” is doing
something better and less expensively than previously possible, then this approach appears
to qualify. The potential to provide evidence-based treatment safely and sufficiently while
avoiding the costs and liabilities inherent in hospital care deserves our careful attention.
From a practice standpoint, the PHP system of service delivery may be within the reach of
many clinician-run organizations. Larger practices may already have sufficient resources
in place and only require a carefully constructed business plan to determine the financial
feasibility of offering this level of care for adolescent patients and their families.
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7
DBT in Inpatient Settings
and Jacob M. Klein
In this chapter, we will discuss adaptations for DBT in inpatient hospitalization settings.
An inpatient unit is an ideal setting to implement DBT, as it provides a short-term,
immersive experience for adolescents that specifically targets their life-threatening
behaviors and the resulting hospitalizations. In fact, the underlying goal of an inpa-
tient DBT program is to help the client use skills and reduce problem behaviors so he
or she will not need to be hospitalized in the future (Swenson, Witterholt, & Bohus,
2007). Because being hospitalized is often unintentionally reinforcing for adolescents,
having the program, or milieu (inpatient environment), structured around DBT will
help reduce that reinforcement. In addition, the implementation of a DBT program
may reduce staff burnout, as it provides them with the training and skills to work
effectively with extremely dysregulated adolescents.
Preliminary research supports the use of DBT on inpatient units (Linehan, 2015).
Studies have found that an inpatient DBT program can reduce behavioral problems
(Katz, Cox, Gunasekara, & Miller, 2004), increase positive treatment outcomes and
reduce non-suicidal self-injury (McDonell et al., 2010), and provide long-lasting remis-
sion of mental health symptoms (Kleindienst et al., 2008). Though these results are
promising, they remain preliminary, and therefore you should be mindful of your pop-
ulation, and availability of other evidence-based treatments before implementing DBT.

Implementing DBT on an inpatient unit requires a significant amount of adaptation
from the standard DBT model that was designed for outpatient settings. Basically, you
will be taking a treatment intervention that was developed to be implemented over
six months, and adapting it to be implemented over the course of several days. How
you will adapt DBT will depend largely on the average length of stay in your program.
This can vary greatly—you may be in a residential setting, where you have up to sev-
eral months to implement standard DBT, or you may have only a few days. Regard-
less, you will need to spend a lot of time considering the best way to determine that
the client receives the essential skills necessary for successful coping upon discharge.
You will also need to consider whether you are going to implement a full model
that includes all DBT functions and modes (see Chapter 2), or only implement certain
85
modes of treatment. For example, implementing the skills group only is common on
inpatient units; however, there is a lack of research supporting the effectiveness of
this approach (Swenson et al., 2007). This decision will be based on your population,
the average length of stay on your unit, and your access to resources and training. For
example, if you are working on a traditional acute care inpatient unit, full DBT may
be warranted to help adolescents eliminate life-threatening behaviors and reduce the
frequency of hospitalizations. However, if you do not have the resources or ability to
engage all of the unit staff in training, it may be best to start with the skills group to
acquaint staff and administration with the underlying tenants of DBT until you are
able to attain the backing and assets to implement the full model.
The existing program may influence your decision regarding whether to adopt or
adapt DBT. For example, if the current program has been in existence for a while,
it may be more challenging for you to implement such an extreme paradigm shift
from the current treatment approach. You may experience resistance from unit staff
(nurses, psychologists, technicians, etc.), as DBT focuses less on punitive punishment
for problem behaviors, and instead highlights the importance of behavioral reinforce-
ment. In addition, staff availability to help clients generalize skills and reinforce skillful
behavior in the moment is essential, which may be a major shift from the current
approach in your program (Swenson, Sanderson, Dulit, & Linehan, 2001). To combat
this, you will need to work hard to attain staff and administration commitment. Using
the commitment strategies we discuss in Chapter 2 can be a useful strategy, as well as
using available data and research to show them the possible benefits of making such
a drastic clinical change (Miller, Rathus, & Linehan, 2007). You can also emphasize
the potential for the program to reduce behavioral problems on the unit. For exam-
ple, several years ago, I worked on an (non-DBT) inpatient unit for adolescents. One
adolescent (who had already displayed a pattern of behavior problems) approached
a staff member and stated, “I’m bored.” The staff member, not unkindly, replied,
“Group will be starting soon,” and went back to what she was doing. The adoles-
cent, still bored, proceeded to disrupt another group of adolescents across the room.
When one of them asked her to leave them alone, the adolescent grabbed her by the
hair, pulled her out of her seat, and proceeded to punch her repeatedly. As you can
imagine, this caused a flurry of activity, restraint of the adolescent, and distress for
the other adolescents on the unit. I often think of this incident and wonder if things
would have been different if the staff member, instead of briefly responding to the
adolescent, had coached the client to use her skills to find an activity to keep herself
busy until group started. Perhaps the whole altercation could have been avoided.
Regardless, by using DBT consistently to coach adolescents on an inpatient unit, staff
may be able to reduce behavioral issues on the unit, thus making their jobs easier and
more enjoyable.
One of the major facets of DBT is the client’s ability to make a decision regarding
whether to engage in DBT or not, as this drastically increases the client’s commitment
to treatment (Linehan, 1993). Optimally, the client should have the ability to choose
regardless of the setting, and if at all possible the adolescent should be provided the
option of engaging in either DBT program, or another non-DBT program. This may
86
be difficult to achieve, unless the hospital you work in has more than one unit. Some
researchers have altered which group sessions the patient will engage in based on
whether or not he or she has committed to DBT treatment—those who have com-
mitted attend skills group, and those who do not attend a pre-commitment group,
which has the goal of facilitating the client’s commitment to DBT (Swenson et al.,
2007). Regardless, if you are not able to find a way to offer an alternative treatment,
you will need to work even harder upon admission to gain even a small amount of
commitment from the client to engage in DBT, even if that is only for a day, or a cou-
ple hours.
Finally, you will need to consider parent and family participation. Again, this may
depend on the average length of stay in your program. For example, some acute
hospitalization settings have an average length of stay of three to five days. With
this short time period, it may be difficult to fully engage adolescents, much less the
parents, in treatment. However, family members should be included in one or two
individual sessions with the primary therapist, so they can understand the behavioral
reinforcement involved in the client’s problem behaviors, and learn skills to help the
adolescent generalize the use of those skills after discharge.
ADDITIONAL TREATMENT TEAM MEMBERS

There are a few additional treatment team members on an inpatient unit, and in an
ideal situation, all staff involved in treatment will be fully trained in DBT and regularly
engage in DBT consultation meetings. On an inpatient unit, staff members surround
adolescents, who can provide positive reinforcement for skills use, and in-the-mo-
ment skills coaching when adolescents need guidance to handle emotion dysregu-
lation effectively (Swenson et al., 2007). This is an excellent asset to DBT inpatient
programs—the adolescent will consistently receive reminders to use skills and get
intentional validation and reinforcement for engaging in skillful behavior. Due to the
intensive and frequent nature of these interactions, consultation is essential for staff,
although this can be complicated with variations in the days and times of their shifts.
You can alter these meetings by providing brief consultation meetings several times
a week, or providing consultation as needed in the moment, at the staff member’s
request (Swenson et al., 2007).
Outpatient Therapist
The outpatient therapist is an ancillary treatment team member in this adaptation,
and has a unique role. The therapist should be aware the adolescent has been hos-
pitalized, and hopefully has provided helpful information to the inpatient therapist
regarding the adolescent’s treatment. However, the outpatient therapist should have
little to no contact with the adolescent during hospitalization. This is mainly to prevent
reinforcement of life-threatening behaviors (see skills coaching in Chapter 1); how-
ever it can also help the client become immersed in the inpatient unit until discharge.
87
Though it would be ideal if the outpatient therapist were a DBT therapist, if they are
not, they should at least be aware of the DBT approach and any behavioral reinforce-
ment related to the client’s life-threatening behaviors that have come to light during
their time in your program (Swenson et al., 2001).
Primary Inpatient Therapist

The primary inpatient therapist has the traditional role of treatment planning, review-
ing diary cards, and committing (and recommitting) the client to treatment. How-
ever, the inpatient therapist also works to help the client plan for discharge. This
can include helping the client identify barriers to success upon discharge, facilitating
family sessions to increase the likelihood of success, resolving any conflicts in the
invalidating environment, and engaging the client in behavior chains when he or she
engages in (or has the urge to engage in) life-threatening behaviors.
Nurses, Psychiatrists, and Other Unit Staff Members

As mentioned previously, all staff members on the unit will have an important role
in helping the client learn and generalize DBT skills, as they will have frequent inter-
actions with them throughout their stay. In addition to this role, they will also need
to engage in consultation to the client. Due to the intensive nature of an inpatient
unit, an adolescent may have a problem with one staff member, and then approach
another staff member in an attempt to resolve the issue. In these types of situations, it
is important that staff members help adolescents identify skills they can use to effec-
tively approach the situation, and then help them practice using those skills. Not only
does this facilitate the use of appropriate assertive behavior, but it also prevents the
adolescent from causing conflict between staff members (Linehan, 1993).
ADAPTATIONS TO TREATMENT TARGETS FOR INPATIENT SETTINGS

The treatment targets for adolescents in inpatient settings are similar to those in
standard outpatient DBT. However, researchers have highlighted a few differences—
they identify unit/milieu interfering behaviors as well as outpatient therapy-interfering
behaviors that led to hospitalization in the first place. They also target quality-of-life-in-
terfering behaviors that occur on the unit, and in outpatient settings (Swenson et al.,
2007). See Table 7.1 for examples of treatment targets in inpatient settings. Ado-
lescents should work together with their primary clinician to identify the treatment
targets on which they will work (with life-threatening behaviors at the top) and then
start by engaging in a detailed behavior chain on the behavior that led them to be
hospitalized. The goal of this is to notice any aspects of the chain that reinforced the
adolescent for engaging in the life-threatening behavior—for example, feeling loved
and cared about by others, when they didn’t prior to the behavior (Swenson et al.,
2001).
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Table 7.1 Treatment Targets for Inpatient DBT

Urges to harm self or others
Thoughts of harming self or others
Voicing a desire to harm self or others
Hoarding items in an attempt to harm self or others
Inpatient Therapy-Interfering Being disruptive in group sessions
Behaviors Not practicing skills or completing diary card
Sleeping in group sessions
Arguing and/or yelling at unit staff
Refusing skills coaching
Outpatient Therapy- Not completing diary card or homework
Interfering Behaviors Arriving late to sessions or missing them completely
Overstepping boundaries with the therapist (e.g., calling
the therapist in crisis repeatedly)
Parents:
Unintentionally reinforcing life-threatening behaviors
Inpatient Quality-of-Life- Arguing/yelling and/or fighting with other adolescents
Interfering Behaviors on the unit
Destroying or vandalizing unit property
Engaging in sexual relationships with other adolescents
on the unit
Not engaging in basic hygiene activities
Outpatient Quality-of-Life- Substance use
Interfering Behaviors Risky sex and other impulsive behaviors
Arguing with parents/not completing chores
Distress Tolerance
Emotion Regulation
SPECIFIC SKILLS AND ADAPTATIONS FOR INPATIENT SETTINGS

There are a few adaptations to DBT for inpatient settings. Foremost, similar to the
format presented by Del Conte in Chapter 6, researchers have identified three stages
in inpatient DBT treatment—getting in, getting in control, and getting out (Swenson
et al., 2007). During the getting in phase, the client is oriented to the unit, formally
commits to DBT, and works together with the primary therapist to identify treatment
89
targets. During the getting in control phase, the client works to learn and generalize
skills, and conducts behavior chains as needed to address problem behaviors. Finally,
during the getting out phase, the client works together with the therapist to plan for
discharge, and prepare for challenging situations once discharged so he or she will be
less likely to engage in life-threatening behaviors and be hospitalized again. Swenson
et al. (2007) recommend celebration and affirmation when the client successfully
transitions from one phase to the next, which will culminate in a graduation cere-
mony when the client is discharged, to reinforce their progress and skillful behavior,
and also as a model of treatment success for other adolescents on the unit.
Contingency Management
Contingency management on inpatient units is as standardized as possible, so that
staff members can respond consistently to problem behaviors. In the event the client
engages in a problem behavior, he or she is instructed by staff to complete a behavior
chain regarding that behavior. Though, at first, the adolescent may need guidance
and coaching from a staff member, after having practice, the adolescent should be
able to complete this on his or her own. After completing the behavior chain, the
adolescent will either process the behavior chain individually with a staff member or
during group with peers and the group leader (this will vary based on the problem
behavior and the set up for your program). Finally, if necessary, the adolescent will
make repairs by identifying how he or she will keep from engaging in the problem
behavior in the future (Swenson et al., 2001; Swenson et al., 2007; Katz et al., 2004).
Skills Adaptations
Due to the nature of the setting, you may have a very limited time to teach adoles-
cents skills, and as result you may not be able to teach them all. As a result, you will
need to focus on the most important skills for stabilization and preventing re-admis-
sion, which will likely be mindfulness skills, distress tolerance skills, and validation
and behaviorism from the walking the middle path module (Swenson et al., 2001;
Swenson et al., 2007; Katz et al., 2004; Miller et al., 2007).
The primary therapist can teach the adolescent the basics of mindfulness upon
admission, and then he or she should be invited to engage in mindfulness activities
frequently throughout the day—either as scheduled with others in the unit, or on his
or her own. Though the focus will be on mindfulness, distress tolerance, and walking
the middle path, skills from the other modules can be included, and should be chosen
to specifically facilitate the client’s coping in the moment as well as after discharge.
Mindfulness of Current Thoughts

This mindfulness exercise can be especially helpful for adolescents who are in an
inpatient setting. There are often situations on an inpatient unit where the adolescent
has little control, yet he or she still has to cope with a situation—for example, when
90
another adolescent on the unit begins to act out aggressively, and staff need to inter-
vene. By being aware of their thoughts in the moment, adolescents can differentiate
between thoughts and emotions, and also notice if they are having thoughts or urges
to engage in a life-threatening behavior (Linehan, 2015).
Self Soothe the Five Senses

This skill can be important for adolescents on an inpatient unit, as the milieu should
be designed to be comfortable but not overly comforting, to reduce reinforcement
of problem behaviors for hospitalization (Swenson et al., 2007). As a result, it can be
helpful for the adolescent to identify things they can use to self soothe their senses.
This can be done during group, and the group leader can facilitate the adolescents to
build a ‘self soothe’ box where they can gather objects to soothe all of their senses,
or they can do this on their own. Soothing all of the five senses may be difficult on an
inpatient unit with few resources—however, with some creativity, he or she should be
able to identify an item that can soothe each of his or her senses. For example, they
can find a picture from a magazine or other source of a beautiful location that they
would like to visit someday. They can seek out a soft craft item, if the unit has one
available (for example, a puff ball or a feather), or use a stress ball, which are often
common on inpatient units. They can also be creative in soothing taste and smell,
and identify one object to use for both—for example, a granola bar that contains
chocolate.
Pros and Cons

Pros and cons can be a great skill for planning for discharge. The client can identify
one (or more than one) problem behavior, and identify what the pros and cons of
engaging in that behavior vs. not engaging in that behavior after discharge. Hopefully
you and other staff members worked with the client using behavior chains to identify
and remove any aspects of the environment that previously reinforced the problem
behavior (for example, his or her parents giving extra validation and attention when
he or she voices suicidal thoughts). As result, there will be more pros to resisting the
urge and using skills (parents will instead provide validation and attention when he
or she acts skillfully). The client can then keep this list, either on an index card or on a
sheet of paper, and keep it somewhere he or she will see it regularly, or carry it around
in a pocket or purse (Linehan, 2015).
Willingness (vs. Willfulness)

This skill is in the distress tolerance module, and can be helpful for any adolescent,
regardless of the setting or diagnosis (see Handout 7.1). By being willing, the client
can choose to do what is needed in the situation, in an effective and mindful manner.
When the client is willful, the adolescent knows what is necessary for the situation,
but refuses to do it, because he or she is in emotion mind. Linehan (1993) provides
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many great metaphors for this, and you can even ask the adolescents to give exam-
ples of times when they were willful (refusing to do chores even though they knew
they would be grounded), and conversely, willing (helping one of their parents out
with yard work, even though they were angry about a disagreement earlier). Often,
when a client is experiencing willfulness, by using mindfulness, he or she can become
aware of it, and use the wise mind to be willing, in the moment. You can also help
adolescents identify different mindfulness activities they can use when they are feel-
ing willful—for example, taking a moment to be present and aware of their body, to
‘find’ their wise mind, before making a decision in the moment.
Cope Ahead for Discharge

This skill includes having adolescents actually envision a situation in which they will
experience the urge to engage in a life-threatening behavior, and then envision them-
selves using distress tolerance skills to resist that urge (see Handout 4.9). This is a
skill that adolescents can learn and practice individually, or during group. If working
individually, they could role-play the situation with a staff member (for example, an
argument with a sibling), and therefore better prepare themselves for actually using
skills when they are experiencing emotion dysregulation (Linehan, 2015).
SAMPLE GROUP SESSION FORMAT

We have included a sample group session format here (see Table 7.2), though the
skills you teach, and the order and frequency by which you teach them, will vary
based on the average length of stay of your program. In standard DBT, completion of
skills training is defined by completing all of the skills modules twice; therefore, ide-
ally, you should try to replicate this in your setting (Swenson et al., 2007). However,
Table 7.2 Sample Skills Training Format for Inpatient DBT
Day of the Week Skills, Activities, and Handouts
Monday Distress Tolerance: Self Soothe, Willingness

Multifamily Skills Group: Behaviorism
Tuesday Distress Tolerance: Mindfulness of Thoughts
Wednesday Emotion Regulation: COPE ahead
Multifamily Skills Group: Validation
Thursday Distress Tolerance: Pros and Cons
Friday Multifamily Skills Group: Behaviorism
Saturday Distress Tolerance: Self Soothe, Willingness
Sunday Emotion Regulation: COPE ahead
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with a short length of stay, this may be difficult to achieve. Your goal will be to choose
the skills you think will be the most helpful for your clients, and present them in a
way that regardless of when they are admitted or discharged, they will receive the
majority of the skills.
Though we focus solely on skills groups in our sample format, there are a lot of other
groups that can be provided throughout the day on an inpatient unit. Goals groups
are common (clients identify their goals for the day; see Handout 7.2) and these can
be geared towards DBT skills use. Other groups can be focused on problem-solving
and consultation for skills use, or even just focus on mindfulness (Swenson et al.,
2007). Generally, you will want to teach skills at least several times a week—and with
a short time frame, you may want to offer them daily. Our format is set up for a week
average stay (common in our experience for acute settings), with skills groups taught
daily for 50 minutes, and multifamily skills groups taught three times per week for
90 minutes. Mindfulness is not included in the skills taught, because in this format it
should be taught upon admission and utilized several times per day after that.
OUTCOME EVALUATION
Though the assessments we have highlighted in Chapter 5 and Chapter 13 are likely
suitable for use in an inpatient setting, we will also highlight a few other options
here. Again, as with all of the adaptations in this book, you will want to choose an
assessment that fits the overall treatment goals of your clients.
Daily Diary Cards

Though diary cards on an outpatient basis are based on daily skills use, and cover
the course of a week, diary cards for acute inpatient stays cover one day, and can be
completed hourly. This can be helpful for you to assess whether the client is experi-
encing a decrease in thoughts and urges to engage in life-threatening behaviors, and
whether they are increasing their skills use throughout the day. See Handout 1.5 for
a sample diary card for inpatient settings.
Crisis Stabilization Scale (CriSS)

The CriSS (Balkin, 2013) was developed to specifically measure adolescent stabili-
zation in acute care settings. It includes 25 items, and takes about ten minutes to
complete. The CriSS has two subscales—Coping, which assesses how the adolescent
is using coping skills, and Follow-up, which assesses the level of the client’s com-
mitment to follow-up treatment after discharge. Although this assessment does not
directly measure DBT coping skills, it can help you evaluate the effectiveness of your
program by administering it to your clients upon admission, and then again upon dis-
charge. It can also help you collaborate with your client on his or her treatment plan,
and make decisions regarding commitment strategies—for example, if a client scores
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low on the Follow-up subscale, you may wish to focus on committing the client to
engaging in outpatient treatment after discharge.
Funding
Inpatient care is costly, and if your client does not have adequate insurance coverage
for treatment, you may have limited ability to treat him or her, if at all. Insurance
will cover inpatient care when medical necessity is established—usually this means
the clients have to be at risk of harming themselves or others, or actively experienc-
ing psychotic symptoms. In my personal experience, some insurance companies may
be more lenient in approving inpatient care for adolescents (e.g., covering a client
who has suicidal thoughts but not intent). However, even if your client does receive
approval for inpatient treatment, they may only approve two to three days at a time,
which can also limit your ability to provide adequate services. Your goal will be to pro-
vide evidence of the benefits of full approval for treatment in your program. This may
include providing the insurance company with outcome data regarding the program’s
effectiveness in reducing the frequency of inpatient hospitalizations (thus, saving the
insurance company money).
Persistent Therapy-Interfering Behaviors

You will likely encounter some adolescents who persistently engage in therapy-inter-
fering behaviors, despite repeated attempts at engaging the client in behavior chain
analyses, and/or working not to reinforce these behaviors, and/or even punishing
those behaviors by removing privileges. Your most important asset when this hap-
pens is your consultation team. By sitting down and analyzing the client’s repeated
behaviors, and problem-solving together, you will be able to come up with a solution.
However, the key is to not “give up,” and if one tactic does not work, simply try
another.
For example, during my intensive DBT training, one team brought up a client who
consistently disrupted group, either by making sarcastic comments about the con-
tent, and/or her peers, or by disrupting group members nearby by whispering to
them. Repeated attempts to redirect and recommit the client were unsuccessful, as
was removing the client from group (this was actually reinforcing—the client did not
want to be there) and removing privileges. All of the teams in the intensive training
(approximately ten) engaged in problem-solving to help out this team, and it took
a while, but we were finally able to identify something that would reinforce her for
behaving during group (not going for participation at this point, just not disrupt-
ing)—a Starbucks specialty coffee. The team decided to offer her the opportunity to
behave appropriately during group, and if she did so, one of her parents would bring
94
her a coffee. The moral of this story is, don’t give up! There is a solution out there; it
may just take time and several DBT clinicians to find it.

Implementing a DBT program on an inpatient unit can be challenging; however, the
behavioral approach to analyzing life-threatening behaviors may be invaluable for pre-
venting re-admission and increasing the clients’ ability to use coping skills. Depending
on your setting, some of your main challenges may be a short time frame to teach
skills, and ensuring that all of the staff have had adequate training, and are working
diligently to provide a DBT milieu that reinforces skillful behavior. Nevertheless, once
these aspects have been addressed, your program may not only increase adolescents’
quality of life, but that of their families, friends, and the community around them.
REFERENCES
Balkin, R. S. (2013). Validation of the goal attainment scale of stabilization. Measurement and
Evaluation in Counseling and Development, 46, 261–269. doi:10.1177/0748175613497040
Katz, L. Y., Cox, B. J., Gunasekara, S., & Miller, A. L. (2004). Feasibility of dialectical behavior
therapy for suicidal adolescent inpatients. Journal of The American Academy of Child &
Adolescent Psychiatry, 43(3), 276–282. doi:10.1097/00004583–200403000–00008
Kleindienst, N., Limberger, M. F., Schmahl, C., Steil, R., Ebner-Priemer, U. W., & Bohus, M.
(2008). Do improvements after inpatient dialectical behavioral therapy persist in the long
term?: A naturalistic follow-up in patients with borderline personality disorder. Journal of
Nervous And Mental Disease, 196(11), 847–851. doi:10.1097/NMD.0b013e31818b481d
McDonell, M. G., Tarantino, J., Dubose, A. P., Matestic, P., Steinmetz, K., Galbreath, H., &
McClellan, J. M. (2010). A pilot evaluation of dialectical behavioural therapy in adoles-
cent long-term inpatient care. Child and Adolescent Mental Health, 15(4), 193–196.
doi:10.1111/j.1475–3588.2010.00569.x
Swenson, C. R., Sanderson, C., Dulit, R. A., & Linehan, M. M. (2001). The application of dia-
lectical behavior therapy for patients with borderline personality disorder on inpatient units.
Psychiatric Quarterly, 72(4), 307–324. doi:10.1023/A:1010337231127
Swenson, C. R., Witterholt, S., & Bohus, M. (2007). Dialectical behavior therapy on inpatient
units. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice:
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8
Working Within School Sites
Richard J. Ricard, Mary Alice Fernandez,
Wannigar Ratanavivan, Shanice N. Armstrong,
Mehmet A. Karaman, and Eunice Lerma
In this chapter we will give best practice recommendations for implementing a Dialectical
Behavioral Therapy (DBT)-informed skills intervention in middle and high school settings.
Given that adolescents spend 30–40% of their day in school environments, it is not sur-
prising that many of the behavioral problems associated with adolescence emerge during
the school day. While the American school system continues to focus primarily on the
traditional academic preparation of students in core subject areas, teachers and admin-
istrators are becoming increasingly aware of the value of school-based mental health
intervention services—estimates indicate that between 14 and 20% of children and ado-
lescents will experience emotional or behavioral distress during adolescence (O’Connell,
Boat, & Warner, 2009). In addition, adolescents are especially vulnerable to family and
social pressure related to rapid maturational changes during puberty, and increasing soci-
etal expectations as they transition to adulthood (Arnett, 1999). Therefore, it is impera-
tive we provide adolescents with as much access to mental health resources as possible.
Clinicians can use school-based interventions to address behavioral problems before
they escalate and require a more intensive intervention (Mazza, Dexter-Mazza, Miller,
Rathus, & Murphy, 2016; Quinn, 2009). Further, the school day provides opportunities
for students to practice adaptive coping in the context in which stressors arise—for exam-
ple, when they experience conflict with peers, or receive a poor grade on an assignment
(Cook, Burns, Browning-Wright, & Gresham, 2010). In addition, many of the barriers clini-
cians face in traditional settings, including parent availability and transportation, are min-
imized or eliminated in school-based intervention services (Mazza et al., 2016). DBT skills
can be easily adapted for classroom or group guidance lessons to increase positive coping
skills and healthy youth development (Alvarado & Ricard, 2013; Mazza et al., 2016).
CONSIDERATIONS BEFORE IMPLEMENTING SCHOOL-BASED

DBT SKILLS GROUP
Administrative and Staff Commitment

Your primary task before going forward with a DBT program in a school will be
attaining commitment and “buy-in” from campus administration. This may be
97
Richard J. Ricard et al.
difficult, and you will need to be deliberate in your efforts to work with administra-
tive, teaching, and counseling staff. It will be most helpful if you can emphasize the
benefits of the program—including the possibility of decreased behavioral problems
and increased academic success. This can be done via a needs assessment you have
conducted on site, or with examples of outcome research from other DBT programs
in schools. Finally, orient staff and administrators to the goals and process of skills
training, the skills deficit model of emotional and behavioral dysregulation, and any
anticipated challenges in program implementation with school personnel (Linehan,
2015).
Availability of Resources and Space

You will need to consider where your groups will take place—the room you choose
should provide for appropriate space to share information and prevent distraction
from other school activities. Standard classroom space is appropriate for implementa-
tion of guidance-based approaches, and smaller group room spaces may be helpful
for smaller and perhaps more intensive therapeutic group work. Finally, ascertain that
you will have appropriate storage space to ethically maintain files and case notes.
Recruitment, Consent, and Assent

Once you have received permission to implement a DBT program, you will need to
decide what your treatment targets will be, and this decision should be based on
the needs of the school. For example, it may be most important to focus on stu-
dents with behavioral problems, or those who struggle with specific mental health
symptoms. It is also likely that students who struggle with stress management and
basic coping skills may benefit from these groups. Regardless, you will also need
to consider student characteristics such as gender and age. Try to make groups
homogeneous, while also being as inclusive as possible (Miller, Rathus, & Linehan,
2007).
After you have chosen your treatment targets, you will need to consider how you
will recruit students to your program. There are a few options for this—students may
be referred to services by teachers and other school professionals, or you may wish
to identify students via a school-wide screening for mental health and/or behavioral
problems (Ricard, Lerma, & Heard, 2013). You can also send home information to
parents regarding the group and have them self-refer if they are interested. There are
pros and cons to all three of these strategies, and instead it may be helpful to use a
combination of these tactics to reach as many participants as possible.
Finally, once possible group participants have been identified, you or another staff
member can invite the adolescents’ parents in for a meeting so you can explain the
program and answer any questions they may have. Though it is mandatory to attain
the parent’s consent, in DBT it is also necessary to attain assent of the adolescent, as
commitment to treatment is one of the largest predictors of success in a DBT program
98
Open vs. Closed Groups

Open groups allow members to enroll at any time while closed groups admit mem-
bers only at the beginning of the group process. There are benefits to both of these
options—in closed groups, members are more likely to develop enhanced cohesion
and familiarity with each other; however open groups provide opportunities for par-
ticipants to experience change and generalize new skills (Linehan, 2015). If the stu-
dents you will be working with have a history of low or sporadic attendance, open
groups may be a better option (Ricard et al., 2013).
Training
DBT is a flexible and manualized approach, and as result, it allows for school-based
professionals (e.g., teachers, counselors, teaching assistants) to be trained and become
members of a DBT consultation team. This is especially useful if you wish to imple-
ment DBT to help adolescents develop basic coping and emotion regulation skills in
a guidance class format. However, if the students you are working with struggle with
severe mental health symptoms, or have significant behavioral problems, you may be
better suited to have a licensed individual with more extensive clinical training imple-
ment the group sessions. The most important characteristic of a group facilitator is
willingness to practice and use the skills before teaching them, as well as the ability
to appropriately self-disclose personal experiences with skills (Mazza et al., 2016).
ADAPTATIONS TO DBT FOR SCHOOLS

A stand-alone DBT skills training group may be the most adaptable element for use
on school campuses. In fact, several researchers have successfully implemented DBT
skills groups with promising preliminary results (Blackford & Love, 2011; Linehan,
2015; Mazza et al., 2016; Ricard et al., 2013). Two examples illustrative of key adap-
tations of standard DBT to school settings are provided below, though we will focus
mainly on the program we developed, Teen Talk.
Skills Training for Emotional Problem-Solving for

Adolescents (DBT STEPS-A)
Mazza and colleagues have written the most comprehensive and contemporary
approach to a school campus-based DBT infused approach referred to as Skills Train-
ing for Emotional Problem-Solving for Adolescents (DBT STEPS-A; Mazza et al., 2016).
The approach is built upon standard principles of DBT (Linehan, 2015) as well as mod-
ifications by Rathus and Miller (2015) for adolescents. The program is applicable to a
variety of adolescent student populations ranging from those without any behavioral
distress to more challenging students. In addition, it is designed to teach adoles-
cents skills for managing difficult emotions, improving relationships, and enhancing
99
decision-making abilities for solving problems and challenges they encounter in daily
living (Mazza et al., 2016).
Teen Talk
A second example of campus-based DBT intervention is the Teen Talk program; a
program my colleagues (first author) and I have been implementing for the past seven
years. Teen Talk is an eight-session DBT infused skills program we created at a Disci-
plinary Alternative Education Program (DAEP) for students who have been removed
from their home campus because of disruptive behavioral problems (Ricard et al.,
2013). DAEP campuses are required to establish intervention plans that support stu-
dent success for reintegration into their home school campuses. Campuses must doc-
ument a student’s response to intervention (RTI). The Teen Talk program was designed
to support the campus’s RTI plan for addressing the emotional reactivity and impul-
sivity that commonly underlies the acute and chronic problematic behaviors of youth
on DAEP campuses.
The Teen Talk program is organized around small group sessions of 45–50 min-
utes twice each week. The sessions are led by counseling interns who work adjunc-
tively with the school counselors. Our team also provides additional support to
school counselors by receiving individual referrals and providing assistance with
school-wide guidance activities. We also conduct school-wide suicide screenings,
and are available for crisis intervention and individual sessions with students experi-
encing distress during their school day. The individual work provides students with
the opportunity to process content, and reinforces the use of skills learned during
group.
Due to the short time frame of the intervention (four weeks), skills are provided in
closed groups that are as homogeneous as possible. Some students exhibit behaviors
that are inappropriate for a group setting; those students are seen individually and
taught skills using variations of the group skills activities. Our adaptation also involves
processing and personal problem-solving during group that is usually reserved for
individual sessions in standard DBT. We believe that students need time to process
difficult situations in their lives, and so we reserve time for discussion of these issues
in the group sessions. However, we work closely with group facilitators to ensure that
group sessions are primarily devoted to introducing and practicing skills. Our leaders
have developed skill in redirecting group members who attempt to monopolize ses-
sions with personal disclosures and what often might be considered bragging about
exploits.
Though Teen Talk is characterized as a stand-alone DBT-based skills training group,
the program includes adaptations of the standard DBT modes, including a consulta-
tion team, individual case management, individual counseling sessions as needed,
and limited phone coaching (mostly parent informational contacts mediated by a
school counselor). Skills coaching may be critical for adolescent clients so they can
seek support and generalize skills throughout the week, and we encourage parent
meetings and counselor consultation whenever possible.
100
Table 8.1 Teen Talk: Treatment Team Members and Roles
Treatment Team Member Roles
School Counselor Primary case manager for students

Refers students to Teen Talk Services
Orients new consultation team members to the site
Provides a minimum of one-hour weekly individual site
supervision for our clinical team
Liaises with teachers and administration
Helps facilitate data collection from teachers on DPR and parent
posttests
Arranges contact with parents when necessary
Group Skills Facilitators Lead skills groups or individual sessions with students
Engage parents and students in orientation to the program
Conduct suicide screenings
Assist with data collection to support program evaluation
Note: natural change agents (i.e., teachers, school personnel)
can also be impactful consultation team members and skills
group instructors
Supervising Faculty Coordinate the clinical intervention at the school site
Provide weekly consultation and supervision
CONSULTATION TEAM MEMBERS AND ROLES

See Table 8.1 for a list of the Teen Talk treatment team members and roles. Our con-
sultation team consists of university student counseling interns (masters and doctoral
level counselors in training), school counselors, and university faculty members. Our
consultation team meets each week to discuss cases and coordinate group activities.
During this time, students receive clinical supervision and opportunities to learn and
practice new skills. The students then take turns demonstrating skills and intervention
techniques to demonstrate mastery before they teach in a group setting (Linehan,
1993). Our skills group facilitators also meet daily with the school counselor who han-
dles referrals, discusses case specifics, and serves as the program liaison to teachers
and campus administration.
TREATMENT TARGETS
School-based treatment targets are focused primarily on: promoting student motiva-
tion and engagement in learning, keeping each individual student and staff member
safe, and maintaining an environment that is conducive to student learning by reduc-
ing individual disruptive, aggressive, and harmful behaviors, and maintaining a posi-
tive interpersonal climate by teaching pro-social skills and civil interactions. Table 8.2
gives examples of common problem behaviors in this setting.
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Table 8.2 DBT Treatment Targets in the Teen Talk Program

Life-Threatening Behaviors Thoughts and/or urges to harm self or others
Engaging in harm to self or others
Bringing a lethal weapon to school
Engaging in fights with a lethal weapon (e.g., a knife)
Classroom/Campus- Arguing with peers, teachers, and administrators
Interfering Behaviors Fighting with peers
Disrupting, skipping, or sleeping in class
Vandalism on campus
Therapy-Interfering Skipping group
Behaviors Acting out behavioral or verbally in group
Insulting or invalidating others in group
Quality-of-Life-Interfering Drug and alcohol use
Behaviors Behavioral problems at home
Stealing, vandalism, and other criminal behaviors
Risky and impulsive behaviors
Increase Behavioral Skills DBT skills modules and opportunities for skill mastery
and generalized homework practice
Skills for life planning and value clarification
OVERVIEW OF TEEN TALK SKILLS GROUP SESSION FORMAT

The format of the groups is standardized, so regardless of the group leader,
each session consists of the same content. The group leader begins by briefly
checking in with each student. Then they review the skills learned in the pre-
vious session and any homework they had been assigned. The group leader
then introduces the new skills, and the clients are invited to practice the skills.
Finally, the homework ‘challenge’ is assigned, the group is closed, and students
are dismissed back to class. Table 8.3 includes an overview of the eight-session
program.
PROGRAM EVALUATION FOR DBT IN SCHOOLS

Student progress can be measured in several ways. Though we have included the
methods of assessment we use in our program, there are a variety of other ways to
measure outcomes, and you will want to consider all of your options based on the
students you are working with.
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Table 8.3 Overview of the Teen Talk Skills Group Sessions
Overview of Skills-Based Group Sessions by Topics and Skill
Session One: Interpersonal Effectiveness and Validation of Others

Session one involves welcoming and introducing students to the group process. The group
members introduce themselves to each other. Students are encouraged to talk about why
they were referred to the DAEP, their current perceptions of the school, and how they
feel about their home school. Group norms for attendance, participation, respect, and
confidentiality are discussed. Ice-breaking exercises that emphasize active listening and
interpersonal validation (Linehan, 1993) are introduced with corresponding activities. The
session sets the tone for group norms on how we expect to interact with each other.
Session Two: Emotion Regulation: Thoughts, Feelings, and Choosing Behavioral
Responses
Session two involves the introduction of mindfulness and contact with the inner world of
thoughts, feelings, behaviors, and choices (Linehan, 1993). These concepts are introduced
with basic activities. Some groups may explore behavior chains.
Session Three: Mindfulness and Emotional Regulation
Session three involves activities related to understanding, describing, and expressing feelings
and emotional experiences. This concept is introduced in exercises that help the students
to contact and explore their feelings and bodily sensations. The activities are coupled with
periods of silence and breathing practice. In a second activity students reflect on the concept
of Minding Your Own Business and are led in reflection of personal business as in an internal
state (thinking, feeling, and emotional experience) in contrast to public behavior. An initial
discussion focused on recognition of private thoughts and feelings as personal. Moments of
silent reflection and mindful breathing are taught as an approach to “mind” or connecting
with our internal selves.
Session Four: Distress Tolerance
Session four focuses on understanding adaptive coping strategies and responses to difficult
emotional situations. Distress tolerance skills involve learning how to cope adaptively and
survive difficult emotional feelings. As a follow-up to the previous session, discussion
focuses on functioning in the context of potentially overwhelming feelings (Linehan, 1993).
Try to Bother Me is an experiential practice in which one person in a group sits in the
middle of a circle of group members and rehearses mindful breathing techniques while the
group members try to bother them (i.e., make them laugh, move, or react). Students are
encouraged to remember that they can make the choice to remain still and peaceful even in
the midst of the chaos that may surround them.
Session Five: Interpersonal Effectiveness Skills
Session five involves teaching effective communication and relating skills. Many students
experience conflictual relationships with their families, peers, and school officials (Mitchell,
Booker, & Strain, 2011). Students are asked to describe the quality of social interactions with
others (family, friends, teachers, counselors) in the past week using the Social Interaction
Questionnaire (SIQ; Ricard, 2009).
(Continued )
Overview of Skills-Based Group Sessions by Topics and Skill

Session Six: Interpersonal Effectiveness (DEAR MAN)
Session six involves a continuation of teaching communication and relating skills initiated
in session five. The session introduces the DBT activity of DEAR MAN to structure the
discussion. The activity is introduced using a humorous pun by asking the students to
draw a “Deer Man” (i.e., a man with deer features like antlers). After students share
their depictions, the traditional DEAR MAN acronym activity is introduced and facilitated
through rounds of role-play. Through role-play scenarios students practice DEAR MAN
communication “to get what you want.” The students role-play peer-to-peer, parent-child,
and student-teacher interactions.
Session Seven: Distress Tolerance Skills
Students are taught skills for acting the opposite of how they feel. Methods of self-soothing
and distracting themselves are adopted from the standard DBT Skills group protocol.
Session Eight: Goal Setting/Committed Action and Smart Goals
The closing session involves a discussion of goal setting and reflecting upon the group
experience. I am SMART is an activity that utilizes the acronym to describe specific,
measurable, attainable, realistic, and time-limited (SMART) goals. Students are coached to
describe at least one short-term goal (in the next two to three weeks) and one long-term
goal. Students take turns discussing each other’s goals and querying each other on the
dimensions of SMART. Finally, students are encouraged to commit to specific actions for
pursuing goals now. In all cases, students are encouraged to reflect upon their time at the
DAEP and return to their home campuses. Encouragement comes in the specific form of
asking “How can things go differently at your home school?” And “What are you willing to
do to make things go differently?”
Session Nine: Transition and Closing (Optional)
Away You Go involves a leader-prepared individualized narrative letter to each student
addressing the process they participated in and the progress they made as a group
member. The leader endeavors to provide honest strength-based feedback in the context of
encouragement and praise for efforts realized during the group process. The general form of
the letter is provided below:
Dear (name),
Throughout these few weeks I have seen your willingness to achieve your goals. You have
learned many skills that will help you with many difficult situations. It is up to you to use these
skills when needed. I am so proud of your work in our group. Good luck in the coming years.
Counselor Signature
Source: Ricard et al., 2013.
The Social Interaction Questionnaire (SIQ)

The SIQ is an instrument developed by Ricard (2009) to monitor each student’s self-as-
sessed quality of interaction with important others (i.e., parents, teachers, friends).
Teen Talk group facilitators often use this to stimulate discussion as part of the inter-
personal effectiveness module.
104
Daily Progress Report (DPR)

The DPR is a checklist, similar to a daily diary card, designed to assess student behav-
ior and engagement during each class period. Teachers complete the form for each
classroom period. Student DPRs are used to assess student compliance with DAEP
procedures and policies as well as specific classroom departments. Students are rated
(1=credit or 0=no credit) on each of four indicators of classroom behavior (arrives to
class on time; participates in class as required; complies with dress code; uses appro-
priate classroom behavior). Students are rewarded for earning credits by receiving
bonus days and recognition, which may result in early release back to their home
campuses. Students carry their DPR with them throughout the day, so they can be
mindful of their behaviors and use skills as needed. Group sessions can include a
review of DPRs, and group facilitators can help the student problem solve to identify
skills they could have used in certain situations, and plan for skills use in the future.
Youth Outcome Questionnaire (Y-OQ)

The Y-OQ (Burlingame et al., 2002) is administered to students and parents as the stu-
dent arrives for orientation to the program. The questionnaire is then re-administered
to all participants as a post-assessment on their last day of attendance. The survey
takes about five minutes to complete. Participants respond to 30 questions indicating
the frequency of situations, behaviors, and moods they experienced in the past week
related to six measures of behavioral distress (aggression, somatic disorders, conflict,
depression, interpersonal relations, hyperactivity, and impulsivity).

Commitment to treatment is a core concept in DBT; however schools are often fast
paced and changing environments, and as result it may be difficult to commit admin-
istrators, counselors, and students to the program. School professionals (adminis-
trators, teachers, and counselors) are stretched by current responsibilities, and the
addition of another program may require extra work. Therefore, it may be challenging
for them to maintain commitment to the program long-term. It can also be frustrat-
ing for teachers when group facilitators regularly request for students to be dismissed
(to counseling) during their class period. In these situations, it will be important for
you to keep school personnel informed about how skills group attendance supports
the overall educational mission for these students.
As you are probably aware, teenagers often get bored and may lose interest in
group sessions over time. To combat this, we work to introduce new and creative
activities in sessions. For example, instead of just describing a typical conflict with
parents, we may ask the students to role-play as a way to help them think about alter-
native behavioral solutions. We also use behavioral reinforcement—the adolescents
often receive very little individualized attention throughout their day, and as result
they appreciate engaging in a positive interaction with an adult during the school day.
105
We also use the DBT commitment strategies (see Chapter 2) frequently and liberally.
For example, during orientation we use foot in the door by encouraging students to
give our sessions a try and if they don’t like them, they don’t have to participate. We
also use the freedom to choose and absence of alternatives by emphasizing the fact
the students have the choice to take part in the groups rather than the mandate to
participate as a response to their behavior. Teen Talk intervention is offered to stu-
dents as an opportunity to learn new ways to manage their emotions if they want to
be successful in school.
CONCLUSIONS AND SUMMARY

School-based DBT is focused on helping students identify adaptive solutions to living.
It can be used as an adjunct to traditional prevention and guidance activities for all
students, as well as with at-risk student populations as a specialized intervention.
In the context of the groups, adolescents have supportive access to personal and
interpersonal resources, and they can then learn to manage their personal difficulties
(Alvarado & Ricard, 2013; Ricard et al., 2013).
A number of researchers have provided best-practice recommendations for evi-
dence-based treatments on middle and high school campuses. Although none of
these recommendations are specific to DBT, many of them emphasize the typical
structural considerations, practical solutions, and lessons learned from implementa-
tion on a school campus (Ruffolo & Fisher, 2009; Fixsen, Naoom, Blase, Friedman, &
Wallace, 2005). These investigations have informed the implementation and best
recommendation practices discussed in this chapter. Personnel training, sustainability,
and evaluation are key components to successful implementation of a DBT program
in a school setting. By working to maintain all of these components, you will be able
to provide a needed service to students, and increase their chances of academic, per-
sonal, and vocational success.
REFERENCES
Alvarado, M. & Ricard, R. J. (2013). Developmental assets and ethnic identity as predictors
of thriving in Hispanic adolescents. Hispanic Journal of Behavioral Sciences, 35, 510–523.
doi:10.1177/0739986313499006
Arnett, J. J. (1999). Adolescent storm and stress, reconsidered. American Psychologist, 54,
317–326. doi:10.1037/0003–066x.54.5.317
Blackford, J. & Love, R. (2011). Dialectical behavior therapy group skills training in a commu-
nity mental health setting: A pilot study. International Journal of Group Psychotherapy, 61,
645–657. doi:10.1521/ijgp.2011.61.4.645
Burlingame, G. M., Dunn, T., Hill, M., Cox, M., Wells, M. G., Lambert, M., & Reisinger, C. W.
(2002). Youth outcome questionnaire (YOQ—30.2). Stevenson, MD: American Professional
Credentialing Services, LLC.
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Cook, C. R., Burns, M., Browning-Wright, D., & Gresham, F. M. (2010) Transforming school
psychology in the RTI era: A guide for administrators and school psychologists. Palm Beach
Gardens, FL: LRP.
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation
research: A synthesis of the literature (Research Report No. 231). Tampa, FL: University of
South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementa-
tion Research Network.
Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New
Mazza, J. M., Dexter-Mazza, E. T., Miller, A. L., Rathus, J. H., & Murphy, H. E. (2016). DBT skills
in schools: Skills training for emotional problem solving for adolescents (DBT STEPS-A). New
Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with
suicidal adolescents. New York, NY: Guilford Press. Retrieved from https://manowar.tamucc.
edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2006-
23301-000&site=ehost-live&scope=site
Mitchell, A. D., Booker, K. W., & Strain, J. D. (2011). Measuring readiness to respond to inter-
vention in students attending disciplinary alternative schools. Journal of Psychoeducational
Assessment, 29, 547–558. doi:10.1177/0734282911406522
O’Connell, M. E., Boat, T., & Warner, K. E. (2009). Preventing mental, emotional, and behav-
ioral disorders among young people: Progress and possibilities [Adobe PDF version].
Retrieved from www.nap.edu/download/12480
Quinn, C. R. (2009). Efficacy of dialectical behaviour therapy for adolescents. Australian Jour-
nal of Psychology, 61, 156–166. doi:10.1080/00049530802315084
Press.
Ricard, R. J. (2009). Social Interaction Questionnaire (SIQ): Measuring social and emotional
climate. Unpublished instrument.
Ricard, R. J., Lerma, E., & Heard, C. C. C. (2013). Piloting a dialectical behavioral therapy (DBT)
infused skills group in a disciplinary alternative education program (DAEP). The Journal for
Specialists in Group Work, 38, 285–306. doi:10.1080/01933922.2013.834402
Ruffolo, M. & Fischer, D. (2009). Using an evidence-based CBT group intervention model for
adolescents with depressive symptoms: Lessons learned from a school-based adaptation.
Child & Family Social Work, 14, 189–197. doi:10.1111/j.1365
Substance Abuse and Mental Health Services Administration. (2014). Results from the 2013
national survey on drug use and health: Mental health findings (NSDUH Series H-49, HHS
Publication No. (SMA) 14–4887). Rockville, MD: Substance Abuse and Mental Health Ser-
vices Administration, (p. 2).
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9
Eating Disorders
In this chapter, we will discuss adaptations to DBT specifically related to eating disor-
ders (abbreviated DBT-ED). Millions of adolescents in the U.S. are diagnosed with an
eating disorder every year (Swanson, Crow, Le Grange, Swendsen, and Merikangas,
2011). Eating disorders have extreme physical consequences, including low blood
pressure, emaciation, cardiac problems, and, in severe cases, death (American Psy-
chiatric Association, 2013). These disorders are also especially dangerous for adoles-
cents, as they are highly correlated with other mental health diagnoses and increased
suicidal thoughts and attempts (Swanson et al., 2011). In light of these findings,
we are charged with helping adolescents overcome disordered eating with the best
approach possible. DBT is well suited for treating eating disorders, because eating
disordered behaviors are often directly related to emotion dysregulation.

The research on DBT-ED is preliminary, and the bulk of this research is on adults who
struggle with bulimia and binge eating disorder (BED). Though a lot of the research on
DBT-ED for adolescents has taken place in outpatient settings, it has also been imple-
mented in intensive outpatient and day treatment settings. Based on the current lit-
erature, there are three different ways to implement DBT-ED for adolescents: DBT-ED
in addition to a current evidence-based treatment, full DBT for stage one clients with
added aspects for disordered eating, and DBT-ED for stage three clients (Safer, Telch, &
Chen, 2009; Federici, Wisniewski, & Ben-Porath, 2012; Bhatnagar & Wisniewski, 2015).
Dialectical Behavior Therapy in Addition to Current Treatment

The majority of research on DBT-ED is focused on implementing DBT in addition to tra-
ditional structured treatments for eating disorders that already have an evidence base.
Researchers posit that using DBT as a supplement to traditional formats could be more
effective in helping clients increase coping skills and decrease emotion dysregulation
(Bhatnagar & Wisniewski, 2015). Further, the current evidence-based treatments avail-
able are not effective for all adolescents—some clients are considered treatment resis-
tant, and the implementation of DBT in addition to traditional treatment modes may
increase positive outcomes for those clients (Wisniewski, Safer, & Chen, 2007).
109
Adding DBT to a current treatment for eating disorders probably sounds like a lot
(and it is), so this is why it is usually only offered in this format for adolescents who are
exhibiting severe symptoms, and are not experiencing positive treatment outcomes.
If you decided to do this, you will need to delineate treatment targets based on the
client’s immediate needs (Bhatnagar & Wisniewski, 2015). In most adaptations where
DBT is implemented in addition to current treatment, all treatment modes (e.g., skills
group, individual and family sessions, consultation group, intersession skills coach-
ing) are implemented. However, this can be time consuming and expensive, and can
include up to two individual and/or family sessions and a family skills group session
weekly. Therefore, it may be more prudent to only implement some modes of treat-
ment, or combine modes to address treatment targets. These adaptations will vary
depending on the setting and resources available; however special attention should
be placed on maintaining the fidelity of the treatment as much as possible.
One example is the combination of DBT and Family-Based Treatment (FBT; Lock &
Le Grange, 2012). Researchers state that these two modalities complement each
other via nonjudgmental stances to treatment, and active but nondirective therapeutic
approaches. In this model, adolescents attended individual sessions, family sessions,
and multifamily skills groups every week. Adolescents were referred to the FBT-DBT
program (as opposed to the FBT-only program) when they were actively engaging in
life-threatening behaviors, were not showing progress in FBT only, were engaging in
significant and severe therapy-interfering behaviors, or had comorbid diagnoses that
also needed to be addressed (Bhatnagar & Wisniewski, 2015).
Full DBT With Added Aspects to Address Eating Disorder Symptoms

There are a few publications that highlight adaptations for clients who struggle with
disordered eating and meet criteria for stage one in DBT. Treatment in these imple-
mentations adheres to the standard DBT model, and includes adaptations for eating
disorder symptoms. For example, skills instruction may be tailored to discuss manag-
ing disordered eating, or you can include a full module that addresses nutrition and
eating behaviors (Federici, Wisniewski, & Ben-Porath, 2012). Other alterations may
include having the clients weigh themselves during individual sessions, and changes
in the rules around phone coaching (this will be discussed in detail later in this chap-
ter; Chen, Matthews, Allen, Kuo, & Linehan, 2008).
Dialectical Behavior Therapy for Stage Three Clients

The adaptation of DBT-ED has the most published literature. As you’ll remember from
Chapter 1, stage three clients do not engage in life-threatening behaviors, either
because they have already been through stages one and two in a DBT program, or
they did not engage in these behaviors in the first place. Clients in this stage have
insight into the fact that their eating disorder behaviors are interfering with their
quality of life, and therefore they are motivated to engage in DBT treatment to spe-
cifically address these behaviors. Since life-threatening behaviors are not a concern
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Eating Disorders
with these clients, treatment targets typically start with therapy-interfering behaviors.
Researchers have also included an extra module on nutrition and eating behaviors in
this adaptation (Safer, Telch, & Chen, 2009).
THE BIOSOCIAL THEORY AND EMOTION DYSREGULATION

IN EATING DISORDERS
In addition to the traditional biosocial theory of emotion dysregulation that highlights
a biological predisposition for emotional vulnerability (see Chapter 1), Wisniewski
and Kelly (2003) posited that individuals struggling with eating disorders also strug-
gle with a nutritional vulnerability. These clients are biologically predisposed to have
difficulty recognizing when they are hungry and when they are full, which can lead
to eating disordered behaviors. Similarly, the invalidating environment can include
messages about body image that individuals receive from peers, family, media, and
Figure 9.1 Biosocial Theory as Applied to Eating Disorders
111
culture (Wisniewski et al., 2007). These messages can be overt—for example, an ado-
lescent being bullied for being overweight, or an adolescent’s parents criticizing her
eating behaviors. However, these messages can also be covert—for example, when
an adolescent is frequently exposed to messages in the media about body images (see
Figure 9.1 for a biosocial theory applied to eating disorders).
ADDITIONAL TREATMENT TEAM MEMBERS
Medical Doctor
As we mentioned, eating disorders can have extremely harmful physical consequences.
As a result, you will want to seriously consider having a physician, nurse practitioner, or
physician assistant as a member of the consultation team. At the very least, the client
should have a medical professional that he or she sees regularly and that you can have
contact with as an ancillary team member. Medical professionals can monitor the client’s
health, and also report on any behaviors the client may be engaging in that might be
considered life threatening. They can also provide support and reinforcement for the
client to use new skills instead of problem behaviors related to his or her eating disorder.
Nutritionist
In addition to a medical professional, you will also want to consider having a nutri-
tionist as a member of your treatment team. The nutritionist can provide individual
sessions to help the client develop healthy eating patterns, and/or lead skills groups
on nutrition to educate clients on the basic functions of food and the body. If you
don’t have a nutritionist as part of your program, you can still work with a nutri-
tionist as an ancillary team member. The nutritionist can be informed of the client’s
treatment plan, and then work with the client based on those treatment targets to
develop an individualized eating plan.
ADAPTATIONS TO TREATMENT TARGETS FOR EATING DISORDERS

See Chapter 1 for a review of hierarchical treatment targets in DBT. Table 9.1 depicts
examples of treatment targets for clients struggling with eating disorders. Life-threat-
ening behaviors may vary based on the adolescent, the severity and frequency of
the behaviors, and the physical health of the adolescent. Regardless, usually eating
disordered behaviors are not deemed life threatening unless a medical doctor reports
an imminent threat to the adolescent’s health (Wisniewski et al., 2007).

Wisniewski and Ben-Porath (2015) highlighted several dialectical dilemmas that
emerge specifically while working with clients struggling with eating disorders. These
112
Table 9.1 Treatment Targets in DBT for Eating Disorders
Primary Treatment
Targets
Life-Threatening Urges, thoughts, or behaviors that harm self or others
Behaviors Eating disorder behaviors that have been deemed life
threatening by a medical doctor
Therapy-Interfering Not completing homework
Behaviors Arriving late to session
Lying about eating disordered behaviors, or omitting information
about these behaviors
Refusing to weigh in
Refusing to maintain agreed-upon weight
Parents:
Quality-of-Life- Engaging in binging, purging, or restricting behaviors
Interfering Behaviors Engaging in excessive exercise
Urges to binge, purge, or restrict
Engaging in Apparently Irrelevant Behaviors (AIBs)
Accessing pro-eating disorder online media
Parents:
Engaging in AIBs that can lead to the adolescent engaging in
disordered eating behaviors (e.g., keeping certain foods in the
house)
Increasing Behavioral Mindfulness (mindful eating)
Skills Emotion Regulation
Distress Tolerance (Urge Surfing, Adaptive Denial)
Burning Bridges and Building New Ones
Alternate Rebellion
Dialectical Abstinence
Secondary Treatment
Targets
Eating Disorder Specific
Dialectical Dilemmas
Structured Eating The adolescent vacillates between over-controlling eating, to not
Plans vs. No Eating being mindful of eating at all
Plan at All
(Continued )

No Activity vs. Not being physically active at all one day, excessively exercising
Over-Activity the next
Apparent Compliance The client claims to be engaging in skills use but is not vs.
vs. Active Defiance actively refusing to engage in aspects of treatment (for example,
weighing in or keeping a food diary)
dialectical dilemmas can be considered secondary treatment targets, and are therefore
only addressed after the primary treatment targets have been satisfactorily resolved.
Structured Eating Plans vs. No Eating Plan at All

This dialectical dilemma refers to the extreme vacillation that clients with bulimia and
binge eating disorder engage in between a rigid over-structuring of their eating plan
and/or significant restriction of calorie intake and having absolutely no structure to
their eating at all, which includes binging. By highlighting this dichotomy, clients and
clinicians can work collaboratively to find the dialectic (perhaps with the help of a
nutritionist), and follow the path to mindful eating.
No Activity vs. Over-Activity

Another dialectical dilemma that is common for clients struggling with eating disor-
ders is either engaging in over-activity (extreme and/or frequent exercise activities) vs.
not engaging in any activity at all. Adolescents may waver between both, or simply
be on one side of this dilemma persistently. Identifying this dilemma, and generating
examples for when this can happen, is helpful, including problem-solving regarding
how to consistently balance between both.
Apparent Compliance vs. Active Defiance

This is an interesting dilemma, and may be especially true for adolescents struggling
with eating disorders. Apparent compliance refers to when the client is engaging in
all requested activities in order to appear engaged in treatment, but is not actually
experiencing meaningful changes. For example, the client may claim to be engaging
in agreed-upon behaviors, but, upon investigation, it is found that the client is not
actually doing so (e.g., a client reports active completion of food logs but repeatedly
fails to produce them in session). Active defiance is exactly as it sounds—when a
client refuses to engage in treatment-related behaviors. When this happens, the cli-
nician should go back to utilizing dialectical and commitment strategies to recommit
the client to treatment.
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Eating Disorders
SPECIFIC SKILLS AND ADAPTATIONS RELATED TO EATING DISORDERS

There are a few skills that researchers have developed or adapted specifically for cli-
ents struggling with eating disorders. Some of these skills were originally adapted for
treating substance dependence with DBT; however Safer et al. (2009) have adapted
them for BED and bulimia as well.
This strategy relates specifically to binge eating for stage three clients (see Handout
9.1). Dialectical abstinence is the idea that the client will commit to abstaining from
binge eating permanently. This commitment is usually made during the pretreat-
ment phase, and is considered essential for the client to continue in treatment.
However, the dialectic involved is that the client must also commit to reducing
binge eating when it does occur by using skills to either stopping the binge eating,
or not engage in binge eating again. The premise of this is that when the client has
been abstaining from an eating disorder behavior and then experiences a ‘slip’ so
to speak, he or she may be feeling discouraged and as result give up and fall back
into the pattern of disordered eating. This synthesis of two seeming conflicting
ideas will allow flexibility for the client to completely abstain when he or she is not
engaged in binge eating, while also working to reduce binge eating when such an
episode does occur (Wisniewski et al., 2007). The idea of committing to completely
abstaining from binge eating is often extremely difficult for some clients to consider.
However, the counselor can use the commitment strategies reviewed in Chapter 2
(e.g., weighing the pros and cons, foot in the door/door in the face) to engage the
client in this commitment and use metaphors to help clients understand the con-
cept. Wisniewski et al. (2007) provide the example of a football player—though at
the beginning of each play, the quarterback’s goal is to score a touchdown, in the
event he does not score a touchdown, he doesn’t give up. Instead, he still tries to
gain as many yards as possible, while still keeping the goal of scoring a touchdown
during the next play.
Burning Bridges
Though we discuss this skill in the context of substance use in Chapter 11, it
is conceptualized a little bit differently for eating disorders. In DBT-ED, burning
your bridges is included in the distress tolerance module—the client is invited
to engage in radical acceptance regarding the idea that he or she will “burn the
bridge” to binging and purging behaviors, and no longer use them as a way
to manage emotions (see Handout 9.2). You can then help the client identify
other skills they can use to replace the old problem behaviors. You can be cre-
ative with this skill; for example, you could include imagery exercises in which
the client envisions actually burning or destroying the bridge to those behaviors
(Safer et al., 2009).
115
Urge Surfing
With this skill, clients are encouraged to be aware of the urge to binge and purge,
but not to act on it (see Handout 9.3). They are taught to be aware of the urge,
experience it as an ebb and flow (like surfing a wave), and in that awareness remind
themselves that the urge will pass. By engaging in this activity without acting on the
urge, clients are better able to regulate their emotions and engage in more adaptive
coping behaviors, which is an important concept to reinforce (Safer et al., 2009).
Again, creativity may be helpful to engage adolescents, either through a mindfulness
activity where you lead them through imagery of surfing through urges (while playing
sounds of the ocean in the background), or having them draw pictures of the ocean
and what surfing the urge would look like to them.
Mindful Eating
Mindful eating is a common skill in many treatment approaches for eating disorders.
Mindful eating is an exercise in which clients are encouraged to be acutely aware
of every bite they are taking, and to slowly savor the flavors, smells, and textures of
their foods. By engaging in this practice regularly, clients will be better able to use
their mindfulness skills to be aware of their eating behaviors, and avoid dialectical
dilemmas such as over-structured eating vs. no structure to eating at all. Clients can
engage in mindful eating exercises during group settings with other clients or alone.
Mindfulness may be more difficult for adolescents to master; therefore you may want
to spend more time practicing mindful eating in session, and use a variety of different
food items to help them learn to use all of their senses (and be aware of any emo-
tional reactions they may be having) while eating. See Handout 9.4 for a worksheet
on this topic.
Alternate Rebellion
Adolescents may engage in eating disorder behaviors as a method of rebelling against
authority figures—for example, parents, teachers, or even the clinician. The adoles-
cent may feel that she has little control—but eating behaviors are one thing she can
control. The goal of the alternate rebellion skill is to help clients validate their urge
to rebel, but do so in a manner that is not harmful and does not include engaging in
eating disordered behaviors (see Handout 9.5). You may need to be creative to come
up with some ideas, but some ideas can include listening to loud or offensive music,
(temporarily) changing his or her physical appearance, or even writing down swear
words on a piece of paper (and then tearing it up and throwing it away).
Phone Coaching Rules

One mode of DBT treatment that researchers have adapted is the intersession skills
coaching (Safer et al., 2009; Wisniewski & Ben-Porath, 2005). Traditionally, in adult
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Eating Disorders
DBT, if a client engages in a problem behavior, the rule is that they may not contact
the clinician for 24 hours after they have engaged in that behavior (Miller et al.,
[2007] actually discourage against this rule for adolescents—you will need to make
your own decisions on this based on the needs of your clients). However, clinicians
found that 24 hours was too long for clients who struggle with disordered eating,
and within that time frame, he or she would have several opportunities to continue
to binge or purge. As result, researchers suggest that this rule be altered in DBT-ED.
Some programs specify a number of hours the client must wait before calling, while
others state the client must wait until the next meal or snack. Regardless, this time
frame can be changed based on the needs of the adolescent, as the goal of phone
coaching is to support the client in using new skills to manage emotions. These
boundaries can be discussed during the pretreatment sessions, and then revisited for
alterations as needed.

The sample group session format presented in Table 9.2 includes all five traditional
DBT modules (Miller et al., 2007) in a six-week format, with the mindfulness module
that includes eating disorder specific skills and psychoeducation on eating disorders
and nutrition (Safer et al., 2009). Sessions can last between one and a half and two
hours, with the first half focused on review and homework, and the second half
focused on new skills. Mindfulness practice should be conducted at least once per
session (see Mindfulness Exercises in Handout 4.2 for a list of sample mindfulness
exercises). Though the skills adapted for eating disorders are mainly taught in the
mindfulness and distress tolerance modules, you may wish to incorporate them into
each of the modules, especially if you have a lot of new participants starting at the
beginning of a new module.
Table 9.2 Sample Skills Training Schedule for DBT-ED
Group Rules
Biosocial Theory of Eating Disorders
Basics of Nutrition
Eating Disorders and Their Consequences
(Continued )
117

Session 3 Mindfulness Practice—What Is Mindfulness?
Mindfulness What Skills (Observe, Describe, Participate)
Session 4 Mindfulness How Skills (One-Mindfully Effectively, Nonjudgmentally)
Session 5 Mindful Eating
Session 6 Apparently Irrelevant Behaviors
Alternate Rebellion
Session 1 Review of Group Rules and DBT Skills Training, the Biosocial Theory,
and Eating Disorders as needed
Introduction to Distress Tolerance and Eating Disorders
Session 2 Urge Surfing
Adaptive Denial
Burning Bridges
Session 3 Distract With Wise Mind ACCEPTS, Self Soothe With the Six Senses
Introduction to Emotion Regulation for eating disorders
Session 2 ABC—Accumulating positive experiences, Build mastery, Cope ahead
(Apparently Irrelevant Behaviors)
Session 3 PLEASE—treat Physical illness, balance Eating, Avoid drugs, balance
Sleep, get Exercise
Eating Disorders

OUTCOME EVALUATION
In addition to the measures mentioned in previous chapters for emotion dysregula-
tion, if you are implementing DBT-ED it is important to assess for eating behaviors as
well. Though we include a few examples here, there may be other methods by which
you can measure your outcomes—focus on what the goal of your program is, and
then choose accordingly.
Diary Cards
Remember, diary cards can be an important indicator of progress in treatment, and
can be tailored to the specific problem behaviors you have targeted. Diary cards are
used in a simplistic fashion—simply keep track of how many times a client engaged
in a behavior on a week-by-week basis. This should give you a good idea if the fre-
quency of occurrences is going down (or up); in addition to letting you know if the
frequency of skills use is increasing. Handout 1.3 is a sample diary card for eating dis-
orders, and Handout 9.6 is a sample Food Log that can also help you track progress.
Body Mass Index (BMI)

Depending on the behaviors the adolescent is struggling with, BMI may be an import-
ant indicator of treatment progress. If the adolescent is struggling with anorexia, an
increase in BMI may be an indication of weight gain, and positive treatment prog-
ress. Though the goal for clients who struggle with binge eating disorder and/or
119
bulimia may not necessarily be to lose weight, weight loss can also be an indicator of
treatment success. There is controversy surrounding the use of specific BMI scores as
benchmarks, due to the differences in body types and bone structure. Therefore, you
should not aim for a specific BMI as part of goal setting for the client, but instead just
use the BMI as one indicator of progress in treatment (Safer et al., 2009).
Child Eating Disorders Examination and Questionnaire

The Child Eating Disorders Examination (ChEDE; Bryant-Waugh, Cooper, Taylor, &
Lask, 1996) was developed based on the adult version, the Eating Disorder Exam-
ination (EDE; Cooper & Fairburn, 1987). The ChEDE is a standardized, semi-struc-
tured interview that the clinician administers by asking the adolescent questions
and recording the responses. It can be used for children and adolescents ages 8–18
and includes four subscales based on cognitive and behavioral symptoms of eat-
ing disorders: restraint, eating concern, weight concern, and shape concern (Van
Durme, Craeynest, Braet, & Goossens, 2015). You also have the option of admin-
istering this assessment as a self-report questionnaire—the Child Eating Disorder
Examination Questionnaire is based on the ChEDE (ChEDE-Q; Decaluwé & Braet,
1999) and includes similar questions regarding eating disorder symptoms over the
last four weeks. Regardless of which method you use, you should be able to get a
solid grasp on your client’s eating behavior. By administering this assessment several
times over the course of treatment, you will be able to adequately measure treat-
ment progress.

One of the biggest challenges you may face is committing the client to treatment.
We say it in every chapter, but it is true! As always, your commitment strategies
will be invaluable to you during the pretreatment phase, and when you need to
recommit the client throughout treatment. Implementing DBT in addition to another
treatment for eating disorders can be expensive and intensive. You can combat this
by combining modes of treatment where possible, and only referring clients to this
treatment who have not been successful in other treatment approaches. As we’ve
also said repeatedly, DBT is extremely flexible—so you can pick and choose the
aspects you wish to implement into your current treatment, and leave the rest. Just
be sure that you are being intentional in what you’re doing, and why you’re doing it.

DBT-ED is structured to treat the underlying emotion dysregulation related to eating
disorders (Safer et al., 2009). In addition, the behavioral aspects of DBT will help you
work with adolescents and their parents to be sure you are not reinforcing problem
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Eating Disorders
behaviors, and instead reinforcing new, coping behaviors. Unfortunately, there is little
research on using DBT with adolescents and eating disorders. Though the research
that is available is promising, evidence-based approaches should be considered before
implementing DBT in place of another approach.
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(Eds.), Family therapy for adolescent eating and weight disorders: New applications (pp.
305–327). New York, NY: Routledge/Taylor & Francis Group.
Bryant-Waugh, R. J., Cooper, P. J., Taylor, C. L., & Lask, B. D. (1996). The use of the eating
disorder examination with children: A pilot study. International Journal of Eating Disorders,
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EAT2260060102>3.0.CO;2-9
Decaluwé, V. & Braet, C. (1999). Child eating disorder examination—questionnaire [Dutch
translation]. Unpublished manuscript, Belgium: Ghent University.
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Lock, J. & Le Grange, D. (2012). Treatment manual for anorexia nervosa: A family-based
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lence and correlates of eating disorders in adolescents. Results from the national comor-
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Wisniewski, L. & Ben-Porath, D. D. (2005). Telephone skill-coaching with eating-disordered cli-
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10
Conduct Disorder, Probation, and
Juvenile Detention Settings
In this chapter we discuss the use of DBT with adolescents who have been diagnosed
with conduct disorder, and/or are involved with the legal system in some manner. This
includes adolescents referred on an outpatient basis due to behavior problems, as
well as adolescents in residential juvenile detention settings. There are several reasons
you may find DBT helpful when working with this population. Many adolescents who
have legal difficulties struggle with mental illness and emotion dysregulation. How-
ever, their symptoms present differently than other adolescents, and they struggle pri-
marily with the ability to regulate anger (Cavanaugh, Solomon, & Gelles, 2011). One
study found that over half of incarcerated adolescents have a history of significant
traumatic experiences, prior mental health treatment, and a substance use disorder
diagnosis (Stewart & Trupin, 2000). Though it is rarely implemented, research shows
that mental health treatment can increase rehabilitation for offenders, and as a result,
reduce rates of recidivism (McCann, Ivanoff, Schmidt, & Beach, 2007). When adoles-
cents do not receive proper treatment for their mental health problems, and instead
experience incarceration or punitive consequences, they may actually experience an
increase in symptoms (Quinn & Shera, 2009).
Many aspects of DBT overlap with evidenced-based treatments for conduct dis-
order in adolescents, including multisystemic therapy (MST; Henggeler, Schoenwald,
Borduin, Rowland, & Cunningham, 2009). For example, MST also includes interses-
sion contact with the clinician, involvement and skills training of parents, and the
introduction of behavioral and cognitive-behavioral skills. Including other aspects of
DBT—for example, dialectics and validation—may increase treatment outcomes with
this population.
The behavioral approach to problem-solving and change in DBT fits well with
reinforcing and extinguishing behaviors related to these disorders. Conversely, as
you have likely noticed, validation is a major facet of DBT, and using validation in
the context of change can increase positive treatment outcomes. Unfortunately,
many evidence-based approaches for behavioral problems in adolescents focus
very little on validating the client, and therefore DBT may be a very helpful option
for clients who do not respond to traditional treatment approaches (Cavanaugh
et al., 2011). Further, when working with this population, counselor (and other
team member) burnout can be high. DBT specifically targets staff engagement
through the consultation team, which can decrease frequency of burnout (McCann
123
et al., 2007; Waltz, 2003). Finally, offenders who receive DBT treatment as part of
their rehabilitation may also continue with DBT treatment after this time is over
and while transitioning from residential to outpatient treatment, which will further
increase positive outcomes and reduce the likelihood of recidivism (Vitacco & Van
Rybroek, 2006).

There are several things to consider before you implement DBT with this population.
As we’ve said with other adaptations in this book, research on DBT with this popula-
tion is preliminary, and other evidence-based treatments may be preferable. A second
consideration is administration and staff buy-in, especially in residential settings. Staff
generalization in skills training is paramount to the success of DBT in a detention or
residential setting. All staff should be well trained in DBT skills as well as skills coach-
ing strategies. This can be done through regular trainings, implementation of DBT
skill use during team meetings, and modeling of skill use by leaders and directors
(McCann et al., 2007). Regardless of the setting, administration will also need to have
a full understanding of the treatment and be committed to making changes related
to implementation. Lack of support from administration can lead to lack of funding
and/or inconsistency in treatment implementation, which can ultimately lead to treat-
ment failure (see Chapter 2).
Parental Involvement and Commitment to Treatment

Even if the adolescent is mandated to treatment (either by his or her parents or
legally), it is important that he or she commit to DBT voluntarily (Galietta & Rosenfeld,
2012). Therefore, clients should be given a choice to engage in the DBT program, or
some other treatment option. It may take a significant amount of time before the
client is willing to fully engage in the treatment; however it is paramount that he or
she makes that choice. Remember, even if you cannot attain full commitment, par-
tial commitment may be enough for the adolescent to start the program until you
can use strategies to commit them fully (refer back to the commitment strategies in
Chapter 2).
One of the primary predictors of treatment success with this population is paren-
tal involvement—perhaps more so than other diagnoses covered in this book, since
symptoms of these disorders are usually directly related to adolescents’ interactions
with their parents as authority figures. The majority (if not all) of the evidence-based
treatments for conduct disorders either include parents in treatment, or focus solely
on the parents and parenting strategies, therefore committing the parents to treat-
ment may be just as important as committing the adolescent. Though it may not
always be possible to include the parents (for example, in a juvenile detention set-
ting), by teaching both parents and adolescents DBT skills, they can work together to
extinguish target behaviors and increase positive coping skills.
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Conduct, Probation, Juvenile Detention
Validation and Nonjudgmental Stance

It is imperative that you approach treatment dialectically when working with ado-
lescents who have committed criminal acts or have problems with conduct. From a
dialectical viewpoint, both the clinician and the adolescent are aware that the adoles-
cent must take responsibility for his or her actions and the clinician is also accepting
and validating of the adolescent’s perspective, including previous experiences that led
up to problem behaviors. Clinicians also take a nonjudgmental stance towards the
adolescent’s behaviors, and separate the behaviors from being “good” or “bad” but
instead view them objectively as a problem that needs to be solved (Waltz, 2003).
One of the underlying tenants in DBT is that the clinician should not “validate the
invalid,” and this can be especially difficult when working with adolescent offenders.
By avoiding validation of the behavior or the offense, it can then be difficult to find
anything to validate. The key is remembering that you can always validate the under-
lying emotions (anger, hurt, etc.) while simultaneously not validating the criminal
or harmful problem behavior. For example, you can say “I can understand how you
felt angry and disrespected when your teacher told you to stop talking in class, and
yelling and knocking over your desk is not an effective way to manage your emotions
and relationships, or get your needs met” (Waltz, 2003).
THE BIOSOCIAL THEORY OF CONDUCT DISORDER

AND CRIMINAL BEHAVIORS
The biosocial theory of emotion dysregulation (see Chapter 1) can be adapted to
address symptoms of conduct disorders, and more specifically, criminal behaviors (see
Figure 10.1). There is a wide range of severity for behavior disorders, and the emo-
tion dysregulation these adolescents experience may be due to a biological sensitivity
to emotions. However, McCann et al. (2007) also postulated that individuals who
exhibit criminal behaviors may actually be experiencing an insensitivity to emotions.
The adolescent may not even realize he or she is experiencing strong emotions until
they are at an extreme level, and this may then lead to aggressive, harmful, and crim-
inal behaviors.
In addition to this possible insensitivity to emotions, researchers have hypothesized
that for individuals who struggle with criminal behaviors and conduct disorder, the
invalidating environment may consist of disturbed caring, an environment in which
antisocial behaviors are modeled. Though this is not always the case, in these situa-
tions the adolescent may view and/or experience physical abuse, inconsistent disci-
pline, and low supervision (McCann et al., 2007).
Regardless, as we discussed previously, your goal will be to take a nonjudgmental
stance when working with parents and adolescents. Remember that the invalidating
environment can be transactional, and that invalidation of the adolescent may be
directly related to his or her behavioral problems and his or her parents struggling to
find ways to manage these behaviors successfully.
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Figure 10.1 Biosocial Theory as Applied to Conduct Disorder/Criminal Behavior
TREATMENT TARGETS WITH ADOLESCENTS WITH BEHAVIORAL

PROBLEMS
Though the treatment hierarchy remains the same when working with adolescents with
behavioral problems, adaptations may be necessary to fit residential settings. For exam-
ple, instead of focusing on decreasing therapy-interfering behaviors, the treatment tar-
gets may include decreasing unit-destroying behaviors. As shown in Table 10.1, these
behaviors include any activity the adolescent engages in that interferes with therapeutic
functioning on a residential unit (McCann et al., 2007; Trupin, Steward, Beach, & Boesky,
2002). Depending on the severity of the adolescent’s mental health symptoms, you may
wish to alter or add different treatment targets—for example, pretreatment goals may
include stabilization on medication for management of severe mental health symptoms
(Vitacco & Van Rybroek, 2006). Nonetheless, treatment targets should be linked back to
criminal behavior and the consequences of all those behaviors (Quinn & Shera, 2009).
Life-threatening and quality-of-life-interfering behaviors are adapted to include
any behaviors that are threatening and harmful to others, in addition to the adoles-
cent. Secondary targets may include decreasing criminal identification and increas-
ing citizenship (McCann et al., 2007). Remember, treatment targets focus on the
problem behavior, but can also include thoughts, urges, and emotions related to
those behaviors, and therefore, all of these aspects should be monitored (Fruzzetti &
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Table 10.1 DBT Treatment Targets and Hierarchy With Conduct Disorders and in Juvenile
Detention Settings

Urges, plans, threats, or thoughts to harm self or others
Unit-Destroying Behaviors Fighting with other adolescents
Arguing/fighting with staff
Destroying unit property
Causing disruption in group
Therapy-Interfering Behaviors Not reporting quality-of-life- or life-threatening
behaviors to the counselor
Not completing diary card or homework
Arriving late to session
Parents:
Clinician:
Being judgmental and/or punitive
Quality-of-Life-Interfering Substance use (see also: Chapter 8)
Behaviors Stealing
Antisocial behaviors
Risky sex
Vandalism
Lying
Fighting
Academic issues
Emotion Regulation (Anger Management)
Distress Tolerance
Decrease Criminal Identification Learn validation and empathy
Increase Citizenship Pro-social skills
Dialectical Dilemma—Excessive Parents allowing the adolescent to not return home
Leniency vs. Authoritarian several nights of the week without any consequences,
Control then suddenly grounding the adolescent for six months.
Levensky, 2000). Finally, when possible, it is important to include treatment targets

related to the parents, as they may be unintentionally reinforcing problem behaviors.
ADDITIONAL TREATMENT TEAM MEMBERS AND ROLES
School Counselor
School counselors can be especially helpful ancillary team members when your
client is having behavioral problems at school. Your goal will be to educate the
counselor on the client’s treatment targets and the DBT approach. The counselor
can then work with teachers to ascertain that problem behaviors are not being
reinforced, and that the use of new coping skills is reinforced. The counselor can
also serve as a skills coach throughout the school day when necessary. The ado-
lescent would then be reinforced for seeking out coaching from the counselor
before he or she engages in disruptive and problematic behaviors at school. Ideally,
teachers would be aware of this and allow the student to leave class to seek out
coaching when needed. Just as with intersession phone coaching, abuse of the
opportunity for skills coaching (e.g., requesting to meet with the school counselor
to avoid taking a test) should not be reinforced (the counselor would immediately
send the student back to class) and the counselor should inform the individual
therapist, who will spend a significant amount of time in the next session engaging
the adolescent in a problem-solving behavior chain (see Chapter 2) regarding this
therapy-interfering behavior.
Probation Officers/Residential Staff

As we’ve said in other chapters, anyone involved in the adolescent’s rehabilitation
should be at least minimally aware of the basics of DBT. If not, they may unintention-
ally reinforce problem behaviors. This is easier said than done—many individuals who
work with the legal system, including staff on residential units and probation officers
have become accustomed to approaching adolescents with a punitive and author-
itarian approach. In addition, they may experience a dialectical dilemma between
keeping themselves safe (using restraints, etc.) and coaching the client to engage in
skills use and distress tolerance to manage the situation (McCann et al., 2007). The
DBT consultation team can provide problem-solving and support as needed to help
other professionals maintain a commitment to the DBT approach.
ADAPTATIONS TO DBT FOR BEHAVIORAL PROBLEMS

AND LEGAL SETTINGS
There are several adaptations for DBT implementation for adolescents with behavioral
problems and in juvenile correctional settings. These include added modules, changes
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in length based on the setting, and use of various treatment modes. Though adap-
tations for outpatient and residential settings might be different, there are also many
overlaps, and you may be working with the same adolescent in both settings. There-
fore, we will discuss them together, and where there are differences we will note them.
Mindfulness
Relational Mindfulness
We also discussed this skill in the chapter on DBT with families, as it specifically
focuses on being mindful of others (see Handout 5.2). By being aware of others, the
adolescent can increase empathy and decrease behaviors that are harmful to others
(McCann et al., 2007). You can encourage your client to use relationship mindfulness
by having him or her think of one specific person and observe and describe them
nonjudgmentally (at first, it’s best if this is someone they either feel neutral or posi-
tive about). After the adolescent has had some practice, he or she can be mindful of
someone they have conflict with—for example, a parent, teacher, or probation offi-
cer. By nonjudgmentally describing the individual, they will hopefully be able to see
the other’s perspective more clearly, which will increase their ability to be empathetic
toward that individual.
Do What Works
This skill is included in Rathus and Miller’s (2015) skills manual and fits perfectly
for adolescents who struggle with managing anger and impulsivity towards
authority figures and parents (see Handout 10.1). The steps to this skill are 1)
Focus on your goals, and 2) Do what needs to be done to achieve your goals,
including: not letting your emotions control your behaviors, playing by the rules,
and acting as skillfully as you can. A metaphor that works really well with this skill
is playing in a football or basketball game. Players have to play by the rules, or get
penalized and/or be removed from the game. Though in the moment, getting in
a fight with a player on the opposite team may seem worth it, the bigger picture
is winning the game. “Doing what works” in this scenario is using distress toler-
ance skills to avoid a fight, and instead focus on playing the game. It may help
to show a short video clip of a famous basketball or football player walking away
from a possible conflict, and then discuss what the process may have been like
for that player, and what they notice about his or her body language in the video
Emotion Regulation
Anger outbursts will likely be common quality-of-life- and therapy-interfering target
behaviors when you are working with this population. Anger, irritability, and related
129
behaviors are diagnostic criteria for conduct disorder, and these behaviors can lead to
innumerable other problems when the client is unable to manage this emotion effec-
tively. All of the different facets of anger, including triggers, false beliefs, and specific
behavioral consequences can be addressed via diary cards and skills.
Though it is imperative to help adolescents understand and explore anger, it is also
important not to overlook the other emotions as well. Anger is a secondary emotion,
and the adolescent may experience many emotions at one time, which increases like-
lihood of maladaptive behaviors in an effort to regulate them (Galietta & Rosenfeld,
2012; Fruzzetti & Levensky, 2000). This module can be altered to help adolescents
understand the primary emotions that underlie anger, which are usually sadness and
hurt. You can also focus on how to communicate emotions effectively to others, and
the link between their thoughts and their emotions.
Acts of Kindness
The goal of this skill is to help adolescents develop empathy and be aware of how
their behaviors affect others (see Handout 10.2; McCann, Ball, & Ivanoff, 2000). Cli-
ents are taught that an act of kindness is done willingly, without expectation of any-
thing in return. They can use the list of kind things on the handout for ideas (for
example, giving a compliment, unexpectedly helping out with a chore around the
house, or helping a teacher with something at school), and they are encouraged to
use this skill often. The goal of this skill is to help the adolescent experience positive
emotions, which will reinforce him or her for engaging in acts of kindness.
Act Opposite to Anger and Apathy

This skill can help adolescents identify the emotion they are currently experiencing,
and then act opposite to that emotion in order to manage it effectively without
engaging in a harmful behavior (see Handout 4.8). Though you will obviously want to
help adolescents use this skill when they are experiencing anger, McCann, Ball, and
Ivanoff (2000) also adapted this skill to help juvenile offenders act opposite to apathy
and detachment. Some examples include engaging in random acts of kindness (see
above), participating fully in group and individual sessions (even when he or she does
not want to), listening mindfully and validating others, and engaging in interactive
activities with family and friends.
Cope Ahead to Manage Anger

This skill can be useful in helping the adolescent plan for situations in which he
may become angry and be at risk for engaging in harmful and/or problem behaviors
(Linehan, 2015; see Handout 4.9). This can include interactions with parents, teach-
ers, and peers. The client can then problem solve and decide how to handle it using
positive coping skills (for example, the STOP distress tolerance skill). Your client will
130
then imagine what the situation will be like, and envision using the identified skills. By
doing this, your clients will be able to effectively “cope ahead” instead of engaging
in destructive or harmful behaviors. This can also go hand in hand with the behavior
chain for problem-solving (see Handout 1.6)—the client can complete the behavior
chain, and then use the imagery to imagine himself or herself using the newly iden-
tified skills (Linehan, 2015).
Distress Tolerance
STOP
This skill is an acronym, for Stop, Take a step back, Observe, and Proceed mindfully
(Linehan, 2015). This can be a fun and helpful skill to practice in group sessions with
clients. For example, having the clients imagine a situation in the past (that is likely to
happen again) in which they engaged in a harmful or aggressive behavior. The clients
can be invited to act out their body language and “set up” the scene, so to speak,
up to the point where they actually engaged in the problem behavior. Then, they can
role-play how they will use the STOP skill in the future, and keep themselves from
engaging in the problem behavior.
Intersession Skills Coaching

Skills coaching between sessions for adolescents who struggle with behavioral prob-
lems will look different based on your setting. For example, similar to an inpatient
unit, coaching in a juvenile detention center may be conducted by unit staff on an
as-needed basis (McCann et al., 2007). In an outpatient setting, it may be difficult to
engage clients who struggle with criminal behaviors, and therefore it may be more
helpful for you to actually schedule times that the client will call for skills coaching.
Some clinicians who work with offenders have actually removed the 24-hour rule (the
client cannot call the clinician until 24 hours after the problem behavior occurred).
You may also wish to consider removing this rule, because clients who have behav-
ioral problems are unlikely to be reinforced by contact with the clinician (especially if
they have been mandated to treatment), and this removes the necessity of this rule
(Galietta & Rosenfeld, 2012).

The sample group session format included in Table 10.2 presents all five traditional
DBT modules (Rathus & Miller, 2015) in a six-week format, with each module includ-
ing the new and adapted skills related specifically to criminal and harmful behaviors
(McCann et al., 2007). Session length may vary—for residential settings, groups may
last an hour, and outpatient groups may last an hour and a half. Usually the tradi-
tional format will work best, with the first half focused on review and homework, and
131
Table 10.2 Sample Skills Training Schedule for DBT for Conduct/Behavioral Problems
Group Rules
Biosocial Theory of Conduct Disorder
Psychoeducation on Conduct Disorder and Emotion Dysregulation
Mindfulness Practice—What Is Mindfulness?
Session 3 Mindfulness What Skills (Observe, Describe, Participate)
Session 4 Mindfulness How Skills
One-Mindfully
Nonjudgmentally
Session 5 Mindfulness How Skills
Effectively (Do What Works)
Session 6 Relational Mindfulness
and Conduct Disorder as needed
Introduction to Distress Tolerance
Session 2 STOP Skill
Session 3 Distract With Wise Mind ACCEPTS, Self Soothe With the Six Senses
and Conduct Disorders as needed
and Conduct Disorders as needed
Introduction to Emotion Regulation for conduct/anger
Session 2 ABC—Accumulating positive experiences, Build mastery, COPE

ahead to manage anger
Session 3 PLEASE—treat Physical illness, balance Eating, Avoid drugs, balance
Sleep, get Exercise
Acts of Kindness
Session 6 Act Opposite to Anger and Apathy
and Conduct Disorder as needed
the second half focused on new skills. Mindfulness practice should be conducted at
least once per session (see Handout 4.2). To review some of the standard skills listed
here, refer back to Chapter 5.
OUTCOME EVALUATION
Alongside the traditional methods of measuring treatment progress in DBT, you will
want to incorporate a method of measuring the specific treatment targets related to
working with juvenile offenders and adolescents with behavior problems. You can
do this fairly easily with a combination of informal and formal assessment methods.
Diary Cards
See Handout 1.4 for a diary card that includes behaviors that are common treat-
ment targets for this population. This can include number of re-offenses, disciplinary
actions, and aggressive or destructive behaviors. As the diary card is self-report, the
133
client may be reluctant to complete it, or to be honest in completing it. You can
approach this using the door-in-the-face commitment strategy (see Chapter 2)—start
by asking the client to complete the full card, and if you are met with resistance, ask
the client to complete a very small portion instead. As the client (hopefully) has made
the voluntary choice to engage in DBT treatment, you can also remind him or her
of that when discussing the importance of honesty in completing diary cards. If you
do become aware that the client has not been honest regarding problem behaviors
that have occurred throughout the week, this can be treated as a therapy-interfering
behavior, and addressed in individual sessions via behavior chain analysis.
Child Behavior Checklist

The Child Behavior Checklist (U.S. Department of Justice, National Institutes of Jus-
tice, Office of Justice Data Resources Program, 2002) assessment is really popular, and
can be used for children and adolescents. It includes several measures, a report form
for parents and teachers, and a youth self-report form. It includes statements regard-
ing the client’s behavior, and then the respondent can rate the frequency she or he
engages in certain behaviors based on a Likert scale. The school age version includes
120 questions, and can also be helpful in diagnosis.
State-Trait Anger Expression Inventory-2

The State-Trait Anger Expression Inventory-2 (STAXI-2; Spielberger, 1999) assess-
ment is considered appropriate for adolescents age 16 and older, and this may be
a limitation depending on the age range of the adolescents you are working with.
This short assessment (5–10 minutes) includes 57 items and six scales—State Anger,
Trait Anger, Anger Expression-In, Anger Expression-Out, Anger Control-In, and Anger
Control-Out (Lievaart, Franken, & Hovens, 2016). Though you may not find all of
these scales helpful in your outcome evaluation, you can choose one or two of these
scales instead, which can reduce the amount of time the adolescent will need to take
to complete the assessment, and give you an accurate picture of the specific variable
you wish to analyze.
Commitment to Treatment
Adolescents who have behavioral problems are often difficult to engage in treat-
ment. As we’ve mentioned, this is likely due to the fact they have been required to
attend treatment, and therefore, commitment to treatment may take longer with this
population. DBT commitment strategies can be used to help engage the client. For
example, the adolescent may be willing to commit to a shorter term of treatment, or
towards positive goals that are perhaps not directly related to criminal offenses (foot
134
in the door). You may also want to highlight the freedom to choose, and the absence
of alternatives: “It’s your choice—you can stay in the current program, that you have
already told me you find to be ‘worthless,’ or you could try out this new program,
and we can work together towards goals we both agree will improve your life and
get your probation officer and your parents off of your back” (Miller, Rathus, & Line-
han, 2007). The adolescent may need to be committed and recommitted to treat-
ment often. Similarly, parents may need to engage in the commitment process several
times. This is especially important during transition periods and after the client has
been released from residential care, as parent commitment may help the client use
skills, and reduce the likelihood of re-offense.
Finally, for adolescents involved in the legal system, you may be asked to release
records, or appear in court to describe treatment progress. This can pose ethical issues
that you will need to be upfront with your client about at the beginning of treatment,
and be clear about who will have access to the records, and what you will and will
not share with others. Not only will this facilitate the development of the therapeutic
alliance, but you will be modeling honestly and genuineness to the client.
CONCLUSIONS
Though the majority of published literature on DBT with juvenile offenders and ado-
lescents with conduct disorder is conceptual, preliminary results are promising (Nel-
son-Gray et al., 2006). Using aspects and adaptations of DBT may be helpful for your
practice. Be sure to weigh the pros and cons of the different aspects of treatment,
and consider supplementing current treatment with a DBT approach. The major ten-
ants of DBT, including a nonjudgmental approach, and working towards change in
the context of validation, may be invaluable for adolescents who have become accus-
tomed to a punitive and authoritarian approach.
REFERENCES
Cavanaugh, M. M., Solomon, P. L., & Gelles, R. J. (2011). The Dialectical Psychoeduca-
tional Workshop (DPEW) for males at risk for intimate partner violence: A pilot random-
ized controlled trial. Journal of Experimental Criminology, 7(3), 275–291. doi:10.1007/
s11292-011-9126-8
Fruzzetti, A. E. & Levensky, E. R. (2000). Dialectical behavior therapy for domestic violence:
Rationale and procedures. Cognitive and Behavioral Practice, 7(4), 435–447. doi:10.1016/
S1077–7229(00)80055–3
Galietta, M. & Rosenfeld, B. (2012). Adapting dialectical behavior therapy (DBT) for the treat-
ment of psychopathy. The International Journal of Forensic Mental Health, 11(4), 325–335.
doi:10.1080/14999013.2012.746762
Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D., & Cunningham, P. B.
(2009). Multisystemic therapy for antisocial behavior in children and adolescents (2nd ed.).
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Lievaart, M., Franken, I. A., & Hovens, J. E. (2016). Anger assessment in clinical and nonclinical
populations: Further validation of the State-Trait Anger Expression Inventory-2. Journal of
Clinical Psychology, 72(3), 263–278. doi:10.1002/jclp.22253
McCann, R. A., Ball, E. M., & Ivanoff, A. (2000). DBT with an inpatient forensic population:
The CMHIP forensic model. Cognitive and Behavioral Practice, 7(4), 447–456. doi:10.1016/
S1077-7229(00)80056-5
McCann, R. A., Ivanoff, A., Schmidt, H., & Beach, B. (2007). Implementing dialectical behav-
ior therapy in residential forensic settings with adults and juveniles. In L. A. Dimeff & K.
Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications across disorders
and settings (pp. 112–144). New York, NY: Guilford Press.
Nelson-Gray, R. O., Keane, S. P., Hurst, R. M., Mitchell, J. T., Warburton, J. B., Chok, J. T., &
Cobb, A. R. (2006). A modified DBT skills training program for oppositional defiant ado-
lescents: Promising preliminary findings. Behaviour Research and Therapy, 44(12), 1811–
1820. doi:10.1016/j.brat.2006.01.004
Quinn, A. & Shera, W. (2009). Evidence-based practice in group work with incarcerated youth.
International Journal of Law And Psychiatry, 32(5), 288–293. doi:10.1016/j.ijlp.2009.06.002
Press.
Spielberger, C. D. (1999). State-Trait Anger Expression Inventory-2. Lutz, FL: Psychological
Assessment Resources.
Stewart, D. G. & Trupin, E. W. (2000, March). Identifying serious mental and emotional distur-
bance with the MAYSI. In A. Kavanaugh & D. Peuschold (chairs), The Massachusetts Youth
Screening Inventory. Symposium presented at meeting of the American Psychology-Law
Society, New Orleans.
Trupin, E. W., Stewart, D. G., Beach, B., & Boesky, L. (2002). Effectiveness of dialectical
behaviour therapy program for incarcerated female juvenile offenders. Child and Adoles-
cent Mental Health, 7(3), 121–127. doi:10.1111/1475–3588.00022
U.S. Department of Justice, National Institutes of Justice, Office of Justice Data Resources
Program (2002). Project on Human Development in Chicago Neighborhoods (PHDCN)
child behavior checklist, wave 3, 2000–2002 (Instrument for ICPSR 13679). Retrieved from
www.icpsr.umich.edu/files/PHDCN/wave-3-instruments/13679-cbcl.pdf
Vitacco, M. J. & Van Rybroek, G. J. (2006). Treating insanity acquittees with personality disor-
ders: Implementing dialectical behavior therapy in a forensic hospital. Journal of Forensic
Psychology Practice, 6(2), 1–16. doi:10.1300/J158v06n02_01
Waltz, J. (2003). Dialectical behavior therapy in the treatment of abusive behavior. Journal of
Aggression, Maltreatment & Trauma, 7(1–2), 75–103. doi:10.1300/J146v07n01_05
136
11
Substance Use Disorders
In this chapter, we will review adaptations of DBT for adolescents who struggle with
substance use disorders (SUDs). Adolescent alcohol and drug use is common, and
research shows that up to 90% of adolescents who struggle with alcohol and drugs
struggle with symptoms of emotion dysregulation as well (Chan, Dennis, & Funk,
2008). In fact, research shows that many adolescents use substances as a way to cope
with difficult emotions (Bukstein & Horner, 2010). Adolescents who use substances
are more likely to engage in impulsive behaviors and experience more extreme men-
tal health symptoms than adolescents who do not use substances, and DBT can help
adolescents replace substance use with more effective coping mechanisms (McMain,
Sayrs, Dimeff, & Linehan, 2007). Although the results are preliminary, there is a large
body of research on using DBT to address substance use, and DBT has been found to
increase treatment compliance and help clients maintain sobriety longer than other
clients who received standard treatment for alcohol and drug dependency (e.g.,
12-step programs and support groups; Linehan et al., 1999).

There are several evidence-based treatments for adolescents who struggle with sub-
stance use (for example, multi-dimensional family therapy), and researchers have
adapted DBT to supplement those treatments (Dietz & Dunn, 2014; Rathus & Miller,
2015). DBT can be especially useful for adolescents who struggle with an SUD and
emotion dysregulation, or whose substance use seems directly related to emotion
dysregulation. DBT may also be an excellent option for adolescents who have not
experienced positive outcomes in other treatment approaches (McMain et al., 2007).
As with the other diagnoses we discuss in this book, you will need to consider the
available treatment modalities and the needs of your clients before adapting or adopt-
ing DBT in your practice.
ADAPTATIONS FROM STANDARD DBT FOR SUBSTANCE USE DISORDERS

Researchers have adapted many of the traditional DBT skills to address SUDs (McMain
et al., 2007). They have also included a few new skills that you will notice are similar
137
to those used in other treatments for substance use. Harvey and Rathbone (2013)
suggested an emphasis on distress tolerance skills, as adolescents who engage in sub-
stance use might struggle most with impulsivity and the inability to regulate intense
emotions in the moment. Some of the adapted skills we discuss below are distress
tolerance skills, to be used in the moment to fight the urge to use, which can be con-
sidered a crisis situation by DBT standards. Therefore, not only are these adapted skills
important, but you will likely want to spend extra time emphasizing all of the distress
tolerance skills and communicate how helpful they can be in maintaining sobriety.
Clear Mind, Clean Mind, and Addict Mind

In DBT for substance use, there are three additional states of mind—clear mind, clean
mind, and addict mind (McMain et al., 2007). See Figure 11.1 for a depiction of
these three states of mind, and Handout 11.1. Addict mind represents the state of
mind the adolescents are in when they are actively using substances—their thoughts
and behaviors are consumed by their substance use. Conversely, the clean mind is
the state of mind clients are in immediately after they have stopped using the sub-
stance. Though they are sober, they are also in a sort of “honeymoon” phase that
often occurs immediately upon becoming sober—their thoughts and behaviors are
so consumed with their elation at achieving sobriety, that they may not be aware of
the challenges they will face when working to maintain sobriety. However, the clear
mind is the dialectic of the addict and the clean mind. When clients are in clear mind,
they are aware of any potential pitfalls that they may face in maintaining sobriety, and
use newly attained skills to manage their emotions effectively. Similar to the states of
mind in standard DBT (emotion mind, reasonable mind, and wise mind; see Chap-
ter 1), adolescents can attain clear mind by using mindfulness skills.
This concept is also included in the adaption of DBT for eating disorders (see Chap-
ter 9). The idea is for adolescents to make an intentional commitment to not use
ADDICT MIND  CLEAN MIND  CLEAR MIND

Addict Mind: singularly focused on using. Thoughts and behaviors are all geared
towards using or preparing to use. Impulsive.
Clean Mind: not using but not well. Naïve to potential dangerous situations, prone
to high risks, and open to falling back into using behaviors. Believes self to be safe and
invincible to future problems.
Clear Mind: both clean and aware of the potential for relapse. Safeguards the self
from potential people, places, and things that might trigger old behaviors. Sets up a
support system to help with cravings.
Figure 11.1 Clear Mind, Clean Mind, Addict Mind
138
substances ever again. However, they simultaneously also commit to reducing sub-
stance use when it does happen (see Handout 9.1). Obviously, the dialectic here is
committing to not using at all, and committing to reducing use when it happens. This
is an important commitment—adolescents who have identified substance use as a
problem behavior must make a commitment to themselves and to others that they
will no longer engage in this behavior. However, often when adolescents experience
a “slip” and use a substance after committing to sobriety, they experience guilt and
shame, and corresponding negative thoughts. They may then completely give in to
their urges to use and fully relapse. By committing to a reduction of use if/when
this does happen, the adolescent can plan ahead to use effective coping skills in
the moment, and hopefully will then continue to make progress towards treatment
goals. Usually a sports metaphor is good for helping adolescents understand this
concept—McMain et al. (2007) use the example of when a runner sets out to run a
race. The runner is absolutely committed to winning that race; however, in the event
it becomes clear that she is not going to win, she commits to doing the best that she
can, and perhaps getting second or third place, as opposed to completely giving up
and dropping out of the race.
Urge Surfing
This skill is common in other interventions for SUDs. When the adolescent experi-
ences an urge to use, he or she is encouraged to experience the desire to use, and be
aware of it, but then use skills until that urge has passed—they can use mindfulness
skills to envision themselves “riding” the urge like a surfer riding a wave (see Hand-
out 9.3). This then will give the adolescent the time to use distress tolerance skills to
control thoughts and emotions until the urge has passed, and remove him or herself
from the situation, if needed. For example, adolescents can remind themselves that
they have the choice of using later, if they wish, which can help them feel more in
control while not giving in to the urge (McMain et al., 2007).
Apparently Irrelevant Behaviors

This is not necessarily a technique, but more like the coping ahead emotion regula-
tion skill in standard DBT. Basically, the client works to identify apparently irrelevant
behaviors (AIBs) that can ultimately lead to substance use (see Handout 11.2). For
example, an AIB could be giving an old friend (who uses, and is likely to offer him
or her the opportunity to use as well) a ride home, or, simply not getting enough
sleep (which leads to the client feeling distressed and therefore more likely to use).
The hallmark of an AIB is that it is a behavior that at the time seems unimportant,
but it can (and frequently does) actually lead to relapse. AIBs are often identified
through completing a behavior chain after the client has used a substance, but they
also can be identified via diary cards, and by noticing emotional patterns and related
activities throughout the week. For example, if the client is reviewing the diary card
and notices she always experiences an urge to use on Wednesdays, she may realize
139
that every Wednesday she goes to the music store she spent time in a lot when she
was high. Though this behavior did not seem like something that would be harmful,
the adolescent can then problem solve to identify an alternative activity on that day
(McMain et al., 2007).
Alternate Rebellion
This technique is also taught to clients who struggle with eating disorders. Adoles-
cents naturally engage in rebellion against authority, and this skill focuses on the idea
that substance use can be a form of rebellion (see Handout 9.5). When you teach
adolescents this technique, you are teaching them to rebel in an alternative, less
harmful way. Again focusing on the dialectic—you can validate the desire to rebel,
while problem-solving for change in reducing substance use. Some examples of alter-
nate rebellion activities may include changing hair color, or dressing in outlandish
clothing. The activity may vary based on what specifically the adolescent wishes to
rebel against, but regardless the goal is to help the client feel satisfied in rebelling
while also not being harmful to him or herself or others (McMain et al., 2007).

Similar to urge surfing, this technique is common in many SUD treatment approaches.
The name of the skill is actually a metaphor for intentionally ending relationships with
people who facilitated the adolescent’s substance use. You can work collaboratively
with your client to “burn” bridges to the past—for example, deleting his or her deal-
er’s phone number, and telling the dealer not to call. Then, you can work together
to help your client “build” new bridges to the future—for example, making new,
sober friends and creating new activities and hobbies. By simultaneously engaging in
both of these exercises, he or she can increase the chances of maintaining sobriety
(McMain et al., 2007). You can have fun being creative with this idea—engage your
clients in a mindfulness exercise where they envision themselves actually burning
these bridges, or have them draw a picture of what the metaphor means to them. In
a safe, supervised, and controlled atmosphere, they could even find things that repre-
sent their old lifestyle and actually burn them as a symbolic gesture of closing off any
routes to their old lifestyle (see Handouts 9.2 and 11.3).
Adaptive Denial
Adaptive denial is a skill that involves helping the adolescent change his or her
thoughts about substance use (see Handout 11.4). The clients work to convince them-
selves that they do not really want to use substances, and instead, reframe thoughts
to convince themselves that they actually wish to engage in some other activity (thus,
denial). This is another strategy to help your clients get through the moment when
they experience an urge to use. You will want to help your client decide on the alter-
native activity beforehand, and it should be something the adolescent enjoys doing,
140
so he or she will be positively reinforced. This could include playing sports, spending
time with sober friends, going to the movies, or playing a video game (McMain et al.,
2007).
ADDITIONAL TREATMENT TEAM MEMBERS AND ROLES

In addition to the traditional treatment team members, there may be a few additional
ancillary treatment team members for adolescents with SUDs. Your clients may (or
may not) find a 12-step program helpful, and therefore they may have a sponsor that
they seek out for guidance and assistance in maintaining sobriety. Ideally, this sponsor
will be aware of your client’s contingency plans, and the premise of DBT, so when
your client does turn to him or her for guidance, the sponsor can respond and guide
your client in a manner aligned with DBT principles. Though many adolescents who
struggle with SUDs do not have any legal problems, a large amount find themselves
in treatment as a direct consequence of their legal troubles. As a result, another com-
mon treatment team member is a probation officer, who is assigned to your client
to monitor him or her, ensure compliance with probation requirements, and possibly
administer drug tests. By seeking a release of information for your client’s probation
officer, you can communicate with this individual to make sure your goals are aligned,
and then the probation officer can contact you if any issues arise, so you can work
together to find the best outcome for the client.
ADDITIONAL TREATMENT MODES
12-Step Support Groups

As aforementioned, support groups similar to or including Alcoholics Anonymous and
Narcotics Anonymous may be helpful for your clients. Though the majority of these
groups are for adults, many cities have a group or two geared towards adolescents.
Though 12-step programs are not for everyone, for many they can be an extremely
helpful venue of support to maintain sobriety.
Parenting/Family Skills Groups

Some researchers have suggested separate parent and family skills groups when
working with adolescents who struggle with SUDs (Harvey & Rathbone, 2013). They
also encourage parents to have their own skills coach. This can help validate parents
as well as help them develop skills and ideas to reinforce positive behaviors. Further,
they discussed the fact that although some parents do decide to use drug testing to
manage and measure drug use, they have found it far more effective to focus on rein-
forcing the adolescent for sobriety and positive behaviors, than focus on drug testing
and punishments. See Handout 4.14 for information on this topic.
141
Treatment Targets
See Table 11.1 for examples of hierarchical treatment targets when treating SUDs. In
most substance use treatments, the goal is for the client to attain abstinence. However,
with adolescents this expectation may simply be unreasonable. Instead, you may need to
focus on harm reduction, and reduction of substance use, while simultaneously working
to commit your client to completely abstain from drug use. When your client refuses
to work on reducing or ceasing drug use, you instead can focus on quality-of-life- and
therapy-interfering behaviors that the adolescent will agree to work on, and then try to
connect those behaviors to drug use as appropriate (Harvey & Rathbone, 2013).
Table 11.1 Adapted Treatment Targets for Treating Clients With SUDs

Life-Threatening Behaviors Urges, thoughts, or behaviors that harm self or others
Substance use that has been deemed life threatening
by a medical doctor
Therapy-Interfering Behaviors Not completing homework
Attending session under the influence of substances,
or not attending session because of substance use
Parents:
Behaviors Urges to use substances
Behaviors surrounding substance use
Symptoms of withdrawal associated with abstinence
Emotion Regulation
Distress Tolerance (Urge Surfing, Adaptive Denial)
Alternate Rebellion
Common Parent/Child Dialectical
Dilemmas
Excessive leniency vs. Parents ignoring outright substance use behaviors,
authoritarian control then suddenly grounding the adolescent for 6 months.
142
Normalizing pathological Vacillating between treating frequent and serious

behaviors vs. pathologizing substance use as normal, and treating other typical
normative behaviors adolescent developmental behaviors as pathological
(e.g., staying out past curfew).
Forcing autonomy vs. fostering Expecting the adolescent to cease substance use with
dependence little to no guidance vs. taking over and making all
decisions for the adolescent.

There are many different ways to implement skills groups, and you will want to adapt
your delivery based on the needs of your clients. The sample group session format in
Table 11.2 presents all five traditional DBT modules (Rathus & Miller, 2015) in a six-
week format, with the mindfulness module that includes the substance use specific
skills and psychoeducation on substance use. These skills can be taught to adoles-
cents and parents/family members in a multifamily group format, or to a group of
only adolescents. Each session should last about one and a half to two hours, with
the first half focused on review and homework, and the second half focused on new
skills. Mindfulness practice should be conducted at least once per session (see Hand-
out 4.2). Though the skills adapted for SUDs are mainly taught in the mindfulness
and distress tolerance modules, you may wish to incorporate them into each of the
modules, especially if you have a lot of new participants starting at the beginning of
a new module.
OUTCOME EVALUATION
One of the most important things you will consider is how to evaluate the success of
your program. Though we provide a few suggestions here, remember to focus spe-
cifically on the goals of your program, and then identify methods of assessment that
align accordingly.
Urine Screens
Urine screens are a very common method of evaluation in substance use treatments,
and Rizvi, Monroe-DeVita, and Dimeff (2007) suggest using random urine screens
to evaluate the success of your program. Though this may not be helpful for all
substances, it may be worth considering, if it is a reasonable option for your site.
However, remember Harvey and Rathbone (2013) encourage the use of positive rein-
forcement of sobriety, and believe that can be more effective than focusing on urine
screens, so you should also keep this in mind.
143
Table 11.2 Sample Skills Module Format
Group Rules
Biosocial Theory of Emotion Dysregulation
Education on Substance Use and Adolescent Brain Development
Addict, Clean, and Clear Mind
Session 3 Mindfulness Practice—What Is Mindfulness?
Mindfulness What Skills (Observe, Describe, Participate)
Session 4 Mindfulness How Skills (One-Mindfully Effectively,
Nonjudgmentally)
Session 5 Burning Bridges and Building New Ones
Session 6 Apparently Irrelevant Behaviors
Alternate Rebellion
Theory, and Substance Use and Adolescent Development as
needed
Introduction to Distress Tolerance and Substance Use
Session 2 Urge Surfing
Adaptive Denial
Session 3 Distract With Wise Mind ACCEPTS, Self Soothe With the Six
Senses
needed
Session 3 Dialectical Dilemmas (as related to substance use)

needed
Introduction to Emotion Regulation for SUDs
Session 2 ABC—Accumulating positive experiences, Build mastery,
Cope ahead (Apparently Irrelevant Behaviors)
Session 3 PLEASE—treat Physical illness, balance Eating, Avoid drugs,
balance Sleep, get Exercise
needed
Diary Cards
See Handout 1.3 for a diary card that is tailored for adolescents who struggle with
substance use. As with all DBT interventions, the diary card is an extremely important
tool for keeping track of problem behaviors, and skills use. By aggregating this data,
you will be able to get a clear picture of how successful your program is at meeting
treatment targets.
Adolescent Substance Abuse Subtle Screening

Inventory—Adolescent
The Substance Abuse Subtle Screening Inventory—Adolescent (ASSI-A2; Lazowski,
Miller, Boye, & Miller, 1998) was designed to screen for the presence of a substance
use disorder in adolescents. It has several subscales, includes questions that can
identify whether the adolescent is responding in a defensive manner, and also has
145
questions that do not seem directly related to substance use to help identify when
your client may not be being completely truthful. Though there is a cost to administer
this test, it may be worth it to have a formalized psychometric assessment to use to
assess the presence of substance use.

We have emphasized commitment strategies several times in other chapters, and
I know you are probably tired of hearing about it (see Chapter 2 to review DBT
commitment strategies). However, they really can be paramount when specifically
targeting substance use with adolescents. This is mainly because the majority of ado-
lescents do not believe their substance use is a problem, and therefore have no desire
to stop using. You can use commitment strategies, in addition to motivational inter-
viewing and assessment of the stages of change, to help the client gain insight into
the problems substance use may be causing them (Dietz & Dunn, 2014).
Relapse is common for individuals who struggle with SUDs. By focusing on dia-
lectical abstinence and distress tolerance skills, your client will learn to work through
urges to use to decrease and then eliminate relapse. However, relapse can be dis-
heartening for you and your client, especially after a sustained period of sobriety.
When this happens, you will need to work together to remember that relapse is part
of the process, and that the client cannot “fail” DBT treatment. In addition, by using
your dialectical strategies (see Chapter 2) you can help the client “make lemonade
out of lemons” and use the relapse as an opportunity to increase his or her ability to
use skills.

As we mentioned in the beginning, though DBT for SUDs is a promising approach,
there still is not a lot of research on it. As result, you’ll want to be intentional about
how you implement it—either in addition to another, evidence-based approach, or
when other approaches have been unsuccessful. DBT is flexible enough that you can
adapt it in many ways, and this may include just implementing specific skills that you
think will work best for your clients. Regardless, you will need to focus on your com-
mitment strategies to help your client see how his or her substance use is keeping him
or her from living a life worth living.
REFERENCES
Bukstein, O. G. & Horner, M. S. (2010). Management of the adolescent with substance use
disorders and comorbid psychopathology. Child and Adolescent Psychiatric Clinics of North
America, 19(3), 609–623. doi:10.1016/j.chc.2010.03.011
146
Chan, Y., Dennis, M. L., & Funk, R. R. (2008). Prevalence and comorbidity of major internal-
izing and externalizing problems among adolescents and adults presenting to substance
abuse treatment. Journal of Substance Abuse Treatment, 34(1), 14–24. doi:10.1016/j.
jsat.2006.12.031
Dietz, A. R. & Dunn, M. E. (2014). The use of motivational interviewing in conjunction with
adapted dialectical behavior therapy to treat synthetic cannabis use disorder. Clinical Case
Studies, 13(6), 455–471. doi:10.1177/1534650114521496
Harvey, P. & Rathbone, B. H. (2013). Dialectical behavior therapy for at-risk adolescents:
A practitioner’s guide to treating challenging behavior problems. Oakland, CA: New Har-
binger Publications.
Lazowski, L. E., Miller, F. G., Boye, M. W., & Miller, G. A. (1998). Efficacy of the Substance
Abuse Subtle Screening Inventory-3 (SASSI-3) in identifying substance dependence disor-
ders in clinical settings. Journal of Personality Assessment, 71(1), 114–128. doi:10.1207/
s15327752jpa7101_8
Linehan, M. M., Schmidt, H. I., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). Dia-
lectical behavior therapy for patients with borderline personality disorder and drug-depen-
dence. The American Journal on Addictions, 8(4), 279–292. doi:10.1080/105504999305686
McMain, S., Sayrs, J. R., Dimeff, L. A., & Linehan, M. M. (2007). Dialectical behavior ther-
apy for individuals with borderline personality disorder and substance dependence. In L. A.
Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications
Press.
Press.
147
12
Other Diagnoses for Consideration
In this chapter we are going to touch on a few other diagnoses that have some exist-
ing research with DBT. These diagnoses include bipolar disorder, major depressive
disorder, and anxiety disorders, including post-traumatic stress disorder (PTSD). The
current research on using DBT with these diagnoses is preliminary, but promising.
Research has shown that DBT treatment can help clients decrease symptoms of anx-
iety and depression, and increase their use of positive coping skills (Neacsiu, Eberle,
Kramer, Wiesmann, & Linhean, 2014; Cook & Gorraiz, 2016). Another pilot study
demonstrated that DBT adapted for adolescents with bipolar disorder significantly
increased positive outcomes in comparison to treatment as usual (Goldstein et al.,
2015). Finally, several studies support the use of DBT with clients struggling with anx-
iety disorders, including PTSD (Harned & Linehan, 2008; Bohus et al., 2013). Though
we will not go as in depth on each of these diagnoses as we have on topics in other
chapters, we will share possible applications of DBT for these disorders, and how you
might use these adaptations in your practice.

As in previous chapters in the text, DBT is often utilized as an adjunct to other evi-
dence-based treatments, or is implemented when the client has not responded well
to other treatments. Due to the vast array of symptoms clients might present due to
these disorders, it will be important to tailor skills for the individual client. Though we
will only discuss a few adaptations of DBT for these disorders, remember that DBT is
a flexible treatment, and all aspects of the treatment can be adapted to intentionally
address treatment targets related to emotion dysregulation.
ADAPTATIONS FOR ANXIETY

Treatment targets for anxiety should be behaviors that the client can control—for
example, panic attacks might not be a treatment target, but things the client can
control that lead up to the panic attack may be—for example, worry thoughts or
catastrophizing. See Table 12.1 for a list of examples of treatment targets related
to symptoms of anxiety. When choosing skills to use with clients who struggle with
149
Table 12.1 DBT Treatment Targets and Hierarchy for Anxiety Disorders

Urges, plans, threats, or thoughts to harm self or others
Therapy-Interfering Behaviors Not completing diary card or homework
Being willful
Parents:
Quality-of-Life-Interfering Worry thoughts
Behaviors Experiential avoidance
Catastrophizing
Judgmental thoughts
Increasing Behavioral Skills Mindfulness/Relaxation
Emotion Regulation
Distress Tolerance
anxiety, be aware of skills that may trigger panic attacks or even flashbacks for clients
who struggle with PTSD (e.g., mindfulness exercises).
Mindfulness of Worry Thoughts

By utilizing the “what” and “how” skills in DBT mindfulness, clients can be aware of their
anxiety in the moment—this includes awareness of their thoughts and beliefs, as well as
any physical sensations that might communicate to them they are beginning to experience
anxiety (Gratz, Tull, & Wagner, 2005). For many clients, worry thoughts are automatic, and
they are not aware they are having them. By using mindfulness, your clients can be present
in the moment, and then be aware of when they are experiencing worry thoughts. This
can be helpful not only in analyzing those thoughts (“Do I really have something to worry
about right now?”) but also noticing the other sensations they are experiencing when they
are having those thoughts—including emotional reactions and physical sensations.
Cope Ahead for Panic Attacks

We have mentioned this skill in previous chapters, as it is flexible and easy to adapt for
target behaviors. By teaching your clients how to cope ahead for panic attacks, they
150
can identify situations in which they foresee experiencing anxiety, identify specific skills
they will use in that situation to manage that anxiety, and then use imagery to picture
themselves using skills in the situation (see Handout 4.9). You will want to be sure the
client has a foundation in skills use and managing worry thoughts before having him
or her practice this skill. Mindfulness exercises before, during, and after this exercise
may be necessary, as imagining the situation can be anxiety inducing in itself.
Acting Opposite of Anxiety

This skill can be a helpful way for your clients to face anxiety-inducing situations;
however the client needs to be able to objectively think about the cause of the anx-
iety, and decide whether it is warranted or not (see Handout 4.8). Linehan (2015)
discusses acting opposite of fear, and the same behaviors can be applicable for anxi-
ety. To act opposite to anxiety, the client will face the situation he or she has anxiety
about, instead of avoiding. He or she can do this while using other distress tolerance
and mindfulness skills, including check the facts, and observe, describe, and partici-
pate skills.
Mindfulness of Others for Interpersonal Effectiveness

Adolescents who struggle with anxiety in social situations may become so focused
on themselves and their anxiety that they have difficulty with relationships—they
may have trouble making friends or standing up for themselves. By focusing on oth-
ers, they can actually decrease their personal anxiety, and act more effectively in the
moment (see Handout 5.2). I once worked with an adolescent who would become so
anxious in social situations that when he started talking, he wouldn’t know when to
stop. As result, he often either said things he didn’t mean to say, or his peers would
stop listening to him. By working on being mindful of others, instead of focusing on
his anxiety in the moment, he focused on the person he was talking to, and how they
were responding to him. We focused on facial expressions and body language. As
result, he was able to manage his anxiety, speak less, and listen more.
Walking the Middle Path—Validation of Self

Adolescents who struggle with anxiety may think negative thoughts about them-
selves related to their anxiety—they may be judging themselves, or believe (correctly
or incorrectly) that others are judging them. By working with your clients to help
them validate themselves, they can decrease judgmental thoughts and increase their
ability to cope with anxiety (see Handouts 4.12 and 4.13). They can do this by identi-
fying the negative thoughts they have about themselves, or believe others are having
about them. Then they can challenge them with validating statements. If your clients
have difficulty with this, remind them of the validating statements they make towards
other group members, or their friends. They can then practice transferring those val-
idating statements to themselves.
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Adaptations Related to PTSD

Though we have not developed any handouts related to this adaptation, we believe it
is important to note that there has been research conducted related to treating PTSD
in the context of DBT. This adaptation integrates exposure-based treatments, and is
called DBT-Prolonged Exposure (DBT-PE; Becker & Zayfert, 2001; Harned & Linehan,
2008; Bohus et al., 2013; Welch, Osborne, & Pryzgoda, 2010). There are three levels
of PTSD-PE. Level 1 includes teaching psychoeducational skills from DBT to increase
the client’s coping skills during exposure therapy. Level 2 includes skills and DBT-based
strategies—for example, validation and dialectical strategies used by the clinician to
increase commitment. Level 3 is the full implementation of DBT, with the inclusion
of exposure-based treatment when life-threatening and therapy-interfering treatment
targets have been achieved (Welch et al., 2010). All three of these adaptations are
based on assessment of the specific needs of the client, including frequency and sever-
ity of symptoms. For example, level 1 clients may be able to use emotion regulation
and distress tolerance to be aware of and cope with emotions during exposure activi-
ties. In level 2, clinicians might incorporate treatment targets and commitment strate-
gies for clients who are engaging in therapy-interfering behaviors, or have more severe
symptoms that must be addressed. Level 3 would likely be reserved for clients who
engage in life-threatening behaviors and experience severe emotion dysregulation.
PTSD is considered a stage two treatment target in DBT, and therefore you will want
to be sure you have addressed any life-threatening and therapy-interfering behav-
iors before moving on to address symptoms of PTSD. There are several adaptations
to standard DBT in DBT-PE, including increased commitment to treatment, regular
assessment of life-threatening behaviors, and the introduction of exposure activi-
ties at a slower pace, with a higher level of involvement by the therapist (Harned &
Linehan, 2008). Remember research on DBT with PTSD is preliminary, and therefore
another evidence-based treatment may be a better fit for your population, for exam-
ple, Trauma-Focused Cognitive-Behavioral Therapy (Cohen, Mannarino, Berliner, &
Deblinger, 2000). You can also consider using aspects of DBT in conjunction with
another approach.
ADAPTATIONS FOR DEPRESSION

Symptoms of depression are highly correlated with suicidal and self-harm behaviors.
Unfortunately, there is very little published literature on specifically working with ado-
lescents struggling with depression. This may be due to the fact that there are several
evidence-based treatments for childhood depression already in place (Chorpita et al.,
2011). However, the majority of these treatments are based in CBT, an approach that
is also included throughout the DBT skills modules. In addition, like other adaptations,
DBT may be helpful for adolescents who have already tried other types of treatment,
and not experienced significant positive treatment outcomes. See Table 12.2 for some
examples of DBT treatment targets for adolescents who struggle with depression.
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Table 12.2 DBT Treatment Targets and Hierarchy for Depression

Life-Threatening Self-injury
Behaviors Thoughts/urges to self injure
Suicide attempts/thoughts/plans/urges
Thoughts of hurting others
Therapy-Interfering Not reporting quality-of-life- or life-threatening behaviors to
Behaviors the counselor
Parents:
Quality-of-Life- Sleeping/staying in bed too much
Interfering Behaviors Isolating
Irritability/anger outbursts
Substance use
Impulsive behaviors
Eating too much or too little
Academic problems
Behavioral problems
Increasing Behavioral Mindfulness
Skills Interpersonal Effectiveness
Emotion Regulation
Distress Tolerance
Loving Kindness
Linehan (2015) included the loving kindness mindfulness exercise as a way for
the clients to share love with themselves or with others. This exercise can be
particularly helpful for adolescents who struggle with depression by having them
share loving kindness with themselves. This exercise consists of cognitively send-
ing kind messages to yourself—much like self-validation, only this takes a step
further because it is not just validating, but sending love and positivity. Though
your clients may find this difficult at first, and may become distracted, you should
encourage them to continue to practice until they can engage in this exercise
with relative ease.
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Acting Opposite to Symptoms of Depression

We have discussed this skill frequently in this book because it is easily adapted,
and can be applied to any emotion your client struggles with. For adolescents who
struggle with depression, it can also be applied to other symptoms related to major
depressive disorder (see Handout 4.8). For example, in addition to acting opposite
to depression and sadness by watching funny movies, or engaging in activities that
make the client feel happy or competent, he or she can also act opposite to anhedo-
nia by getting involved and participating in activities, to fatigue by being active and
getting out of the house to engage in activities, and to guilt by using self-validation
(see Handout 4.13). One of the best ways to identify what an opposite action will be
for the client is having the adolescent identify what he wants to do—for example, go
to bed and stay in bed all day—and then think of the exact opposite of that, which
can be extreme, and at times humorous—for example, going out and running a
marathon. You can then work together to find an activity that is within reason, and
the client is willing to do—like taking a walk. This approach not only helps the client
act opposite to depression, but by identifying something extreme and ridiculous, you
have used the door-in-the-face commitment strategy, so the client is more likely to
be willing to take a walk after comparing it to running a marathon (Linehan, 2015).
ADAPTATIONS FOR BIPOLAR DISORDER

Though DBT is not typically considered for the treatment of Bipolar Disorder (BD),
researchers posit that BD is directly related to emotion dysregulation (Goldstein et al.,
2015). In addition, the risk of suicide in adolescents struggling with BD is high, with up
to 75% endorsing suicidal ideations (Goldstein et al., 2005). Researchers also cite the fact
that there is a paucity of research and implementation of BD treatments specifically for
adolescents, and treatment approaches and goals in DBT align well to address emotion
dysregulation, suicidality, treatment compliance, and interpersonal deficits (Miklowitz &
Goldstein, 2010). Some researchers have adapted DBT for BD by teaching skills in indi-
vidual family sessions, and by extending the length of treatment to one year to allow for
generalization of skills over the course of mood cycles (Goldstein, Axelson, Birmaher, &
Brent, 2007). They also shortened the length of the group sessions to one hour, citing
experiences with adolescents with BD having difficulty concentrating for longer periods of
time. See Table 12.3 for examples of treatment targets for clients who struggle with BD.
Goldstein and colleagues (2007) highlighted the importance of individualizing skills
to specific mood states—this is simply due to the fact some skills may be more helpful
when the client is feeling depressed as opposed to manic. This important distinction
will help clients focus on which skills will work best for them, and which may not be
helpful. For example, when the adolescent is feeling depressed, he or she may wish to
focus on “acting opposite” to his or her emotion as an emotion regulation skill. How-
ever, this may not be appropriate if the client is cycling into an elevated mood, and
therefore he or she may choose an observe or describe mindfulness skill to increase
awareness and manage emotions instead.
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Table 12.3 DBT Treatment Targets and Hierarchy for Bipolar Disorder

Life-Threatening Behaviors Self-injury
Thoughts/urges to self injure
Suicide attempts/thoughts/plans/urges
Thoughts of hurting others
Therapy-Interfering Behaviors Not reporting quality-of-life- or life-threatening behaviors
to the counselor
Not taking medication as prescribed (or not taking it at all)
Parents:
Quality-of-Life-Interfering Substance use (see also: Chapter 11)
Behaviors Stealing
Risky sex
Academic issues
Emotion Regulation
Distress Tolerance
Mindfulness States of Mind—Manic Mind and Depressed Mind

Skills trainers not only discussed the reasonable mind, wise mind, and emotion mind,
but they focused on the different types of emotion mind the adolescent might expe-
rience as related to BD—for example, mania and depression (Miklowitz & Goldstein,
2010). While reviewing each state of mind, adolescents can discuss their thoughts and
emotions during different mood cycles—for example, negative and suicidal thoughts
in depressed mind, and grandiose and racing thoughts in manic mind. They can also
identify any warning signs to when one of these moods may occur, and discuss the
mindfulness activities they can use during these mood states to manage emotions
and act skillfully to keep from engaging in problem behaviors.
155
Mindfulness of Emotions
In alignment with the manic and depressed states of mind, the mindfulness of cur-
rent emotions skill can be adapted specifically for adolescents who struggle with BD.
This skill can be used in the moment to help adolescents notice all aspects of their
emotional state—including physical sensations, thoughts related to their emotions,
and also how other people are receiving them. For example, if the adolescent uses
this skill and is aware of being happy, he or she may not recognize any other warning
signs in his or her thoughts or sensations. However, being aware of how other people
are reacting to him or her can help tell the adolescent if he or she is, in fact, cycling
into a manic episode (for example, if peers seem overwhelmed or confused during
conversations, or shocked by behaviors). Being mindful of all these things in the
moment can help the adolescent be aware of where he or she is with regard to mood
cycling, and then choose skills as needed to manage emotions and seek support.
Radical Acceptance
Radical acceptance may also be a helpful skill to tailor specifically for adolescents
with BD (see Handout 4.10). Not only would this include practicing acceptance of
the fact they are struggling with increased challenges related to their diagnosis, but
also with regard to medication compliance. Adolescents (and adults) are often resis-
tant to psychotropic medication to manage BD, due to the side effects that often
come along with mood stabilizers. As result, it is essential to focus on the importance
of medication compliance, and this can be done by helping adolescents radically
accept medication as an aspect of BD. They can acknowledge that accepting it does
not mean they approve of it, like it, or that they do not have the option to work to
change it (for example, by working with their psychiatrist to find a medication that
is tolerable).
OUTCOME EVALUATION
Though many assessments mentioned in previous sections can be applicable for
working with these diagnoses, you may also wish to consider assessments specific to
the treatment targets and symptoms you wish to reduce. A few of those options are
listed here.
Youth Outcome Questionnaire 2.10 and SR 2.0

The Youth Outcome Questionnaire (Y-OQ) 2.10 and SR 2.0 (Wells, Burlingame, Lam-
bert, Hoag, & Hope, 1996) are both flexible instruments that can be used together—
the Y-OQ 2.10 is completed by the parent, and the Y-OQ SR (self-report) is completed
by the adolescent. These instruments have six scales—intrapersonal distress, somatic,
156
interpersonal relationships, social problems, behavioral dysfunction, and a critical

items scale. Both have 64 Likert-scaled questions. The Y-OQ is popular and clinicians
use it frequently to measure outcomes in outpatient settings, so this may be a good
choice if you wish to measure a few different symptoms.
The Beck Depression Inventory and the Beck Anxiety Inventory

The Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996) and Beck Anxiety
Inventory (BAI; Beck & Steer, 1993) are both popular instruments because they are
short, fairly inexpensive, easy to administer, and very straightforward. There is a lot of
research behind these instruments so they may also be a solid choice for you if you
are looking to measure either depression or anxiety (or both). These instruments are
short enough that you could administer them frequently to track progress—perhaps
monthly or weekly depending on the severity of your client’s symptoms and the inten-
sity of your treatment.

Adolescents who struggle with these disorders will present with a variety of dif-
ferent challenges, and this will depend on your setting and the population you
choose to work with. In general, we recommend that you spend a lot of time
assessing the severity of the client’s symptoms before deciding how to implement
DBT and which skills might be most useful for that client. For example, clients
with very severe depression may have a difficult time with the acting opposite
skill in the beginning, while other clients with less severe symptoms may find it
extremely helpful. Therefore, you will likely need to tailor the skills you teach to
each individual client, which may be time consuming, but will increase positive
treatment outcomes.

DBT can be a great tool for you to use when working with adolescents struggling
with these disorders, but likely should be implemented in conjunction with other
evidence-based treatments. As with the other adaptations of DBT, family involvement
can be extremely helpful, and possibly necessary, depending on the severity of the
client’s disorder. This may be especially true for clients who struggle with bipolar
disorder, as parents may need help identifying problem behaviors and helping the
client use skills to manage extreme emotions during depressive and manic episodes.
Regardless, a dialectical approach of validation and change can help these adoles-
cents effectively regulate their emotions.
157
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13
Comorbid Diagnoses and Life-Threatening
Behaviors
Although comorbid diagnoses and life-threatening behaviors may not seem related,
they are both related to a higher level of symptom severity in adolescents, and there-
fore can both be related to higher risk for chronic mental health problems, and poor
treatment outcomes. Our goal in this chapter is to highlight some specific ways to
address these severe symptoms via DBT. We will discuss skills coaching in more detail,
as well as conducting behavior chain analyses for problem behaviors. We will also
discuss treatment planning for adolescents who have more than one diagnosis.
LIFE-THREATENING BEHAVIORS
Life-threatening behaviors are the primary treatment target in DBT. Though life-threat-
ening behaviors can vary based on the diagnosis, the most common include self-
harm and suicidal behaviors, thoughts, and urges, and so these are the symptoms
we will focus on in this chapter (Miller, Rathus, & Linehan, 2007). Studies have shown
that up to half of adolescents in the U.S. may have engaged in non-suicidal self-injury
at some point in their lives (Lloyd-Richardson, Perrine, Dierker, & Kelley, 2007; Yates,
Tracy, & Luthar, 2008). In addition, suicide has been found to be the number three
leading cause of death among adolescents, and up to 8% of adolescents report
a previous suicide attempt (Centers for Disease Control and Prevention, National
Center for Injury Prevention and Control, 2007) while up to 30% of adolescents
diagnosed with depression endorsed having thoughts of suicide within the past year
(Avenevoli, Swendsen, He, Burstein, & Merikangas, 2015). Suicide and self-injury
are considered two different problem behaviors, because an adolescent engaging in
self-injury often is not attempting suicide, and instead trying to manage intense, dys-
regulated emotions. However, they are highly correlated—adolescents who engage
in self-injury are at higher risk for suicide, and up to 60% of individuals who engage
in self-injury also have thoughts of suicide (Klonsksy, Victor, & Saffer, 2014; Whitlock
et al., 2013).
Every facet of DBT is designed to address suicide and self-harm behaviors, which
makes it an ideal treatment approach for adolescents who struggle with these symp-
toms. Specifically, behavior chains help the client problem solve and stop reinforcement
161
of life-threatening behaviors. Intersession skills coaching reinforces the client for using
positive coping skills. CBT skills taught during the psychoeducational group sessions
help clients distract from intense emotions, and engage in more effective coping
strategies. Finally, the clinician utilizes a dialectical approach to commit the client to
treatment (Linehan, 1993).
Assessment of Self-Harm and Suicidal Behaviors

There are a few formal assessments that can be helpful to monitor and manage ado-
lescent self-harm and suicide-related behaviors. Though you will definitely want to
have the client complete a detailed assessment regarding life-threatening behaviors
upon admission, you may also decide to administer them at regular intervals through-
out treatment, so that you can track treatment progress.
Diary Cards
We highlight the diary card as an assessment tool in every chapter, and there’s a rea-
son for it—the diary card is by far the easiest way for you to track problem behaviors
in DBT. We discuss it more in detail in Chapter 4 (see Handouts 1.2–1.5). By having
the adolescent complete the diary card weekly, you can keep track of how many
self-harm behaviors and/or suicidal thoughts he or she engages in and experiences
in each week (and address them via completing a behavior chain analysis, which we
discuss later in this chapter). You can then keep track over time, to evaluate whether
the frequency of these behaviors and thoughts are decreasing.
Beck Scale of Suicide Ideation

The Beck Scale of Suicide Ideation (BSS; Beck & Steer, 1991) is a short and effi-
cient self-report instrument, with 21 questions that are specifically related to suicidal
thoughts and behaviors over the past week. Though this assessment can be easy
for you to use and administer frequently, it does not include questions on self-harm
behaviors that are unrelated to suicide, and therefore you may need to use another
method of evaluation in conjunction with this assessment to gain adequate informa-
tion on both types of behaviors (for example, the diary card).
Suicide Attempt Self-Injury Interview

The Suicide Attempt Self-Injury Interview (SASII; Linehan, Comtois, Brown, Heard, &
Wagner, 2006) is an assessment that covers both suicidal thoughts/attempts and self-
harm behaviors. This assessment is in the format of a formal interview, is extremely
thorough, and goes through each attempt/self-harm episode in detail on six scales—
suicide intent, interpersonal influence, emotion relief, suicide communication,
lethality, and rescue likelihood. However, the downfall of this is that it may be time
consuming, and therefore may not be suitable for some settings.
162
Comorbid Diagnoses
Treatment Planning With Life-Threatening Behaviors

As we’ve mentioned, life-threatening behaviors are always the first treatment target
addressed in DBT treatment. However, you may have difficulty identifying whether
a behavior is actually considered life threatening. Usually, any thoughts, behaviors,
or urges that are not directly related to harming themselves or harming others are
considered quality-of-life- or therapy-interfering behaviors (Linehan, 1993). However,
depending on what the behavior is, you may decide that it is actually life threatening,
and therefore you need to address that behavior first (for example, a pregnant teen
who is drinking heavily). This is a decision you can make in collaboration with the
adolescent and his or her parents, and you can also seek guidance from your DBT
consultation team.
Another challenge you may face is that the adolescent may be unwilling to iden-
tify a life-threatening behavior as a treatment goal. However, it is paramount that
the adolescent be in agreement regarding which treatment targets you will work
towards, otherwise, success will be unlikely. You can use your commitment strate-
gies (Chapter 2), and shaping, to work with the client to attain at least partial com-
mitment. This can include shorter time frames—for example, a commitment not to
self-harm until the next counseling session. It can also include agreeing on treatment
targets related to the life-threatening behavior—for example, if they are more likely
to engage in self-harm when drinking, alcohol use might be an acceptable alternative
treatment target. You can then continue to use commitment strategies, and help the
adolescent build skills use, until he or she is willing to fully commit to working on the
life-threatening behavior.
Behavior Chain Analysis for Life-Threatening Behaviors

We briefly discussed the behavior chain analysis (BCA) in Chapter 2, and we will
cover it in more detail here as an essential facet of DBT for addressing life-threatening
behaviors. Once you and the client have mutually agreed-upon problem behaviors,
and the client is tracking these behaviors regularly via the diary card, then when the
problem behavior does occur, the next step is to help the adolescent complete the
BCA. At first, this may be an extremely difficult task. Adolescents (and adults) who
are not familiar with going through the process of all of the thoughts, feelings, and
behaviors that led to a problem behavior may have difficulty identifying all of these
factors and how they are related. You will need to walk the client through each step,
and help him or her identify these things. See Figure 13.1 for an example of a com-
pleted diary card regarding an adolescent’s self-harm behaviors, and Handout 1.6 for
our version of the BCA. The first step is always identifying and writing down the prob-
lem behavior, and the consequences of that behavior. After that, I usually encourage
the client to identify any vulnerabilities to the problem behavior—basically, what was
going on in the client’s life that already made him or her more susceptible to engag-
ing in this behavior? This can be a variety of things, including lack of sleep, stress at
school, or some other stressor that the adolescent is having difficulty dealing with
163
Figure 13.1 Behavior Chain Analysis

Source: Adapted by permission from Linehan, M.M. (2015) DBT Skills Handouts and Worksheets. New
York: Guilford Press.
emotionally (e.g., a fight with a friend). Then, we try to identify the prompting event.
Sometimes, this is easily identifiable—an argument with a parent, or a break-up with
a boyfriend or girlfriend. Other times, it may not be a clear, isolated event—and you
may have to back up and walk the client step by step through the day. Once you have
identified it (a thought, e.g., “I think I’m worthless”) then you can walk through all
of the other tiny steps to the behavior (e.g., I felt depressed, I got up and went to the
kitchen to get a knife). Then, you help the adolescent create the new chain of events
by starting with the behavior the client is going to engage in instead. The import-
ant distinction here is that the alternative chain should lead to something the client
will do, not just the lack of the problem behavior. This can include taking a walk, or
spending time with friends. Finally, the adolescent builds the steps to this new behav-
ior, which can include engaging in distress tolerance skills and contacting the clinician
for phone coaching (Linehan, 1993).
Phone Coaching for Life-Threatening Behaviors

We briefly discuss phone coaching in Chapter 2; however, we will discuss here it
in more detail. The DBT approach to handling life-threatening behaviors may feel
dissonant to your clinical training—we are often taught that if clients are a risk to
themselves or others, that we must immediately intervene to get them help, and this
164
Comorbid Diagnoses
often means inpatient hospitalization. However, in DBT the goal is to avoid hospi-
talization if possible, as this can inadvertently reinforce the client’s life-threatening
behavior. As a result, phone coaching guidelines are structured around helping cli-
ents advocate for themselves, and reinforcing them for using skills to cope in crisis
situations, instead of engaging in life-threatening behaviors. As we mentioned in
Chapter 2, clients must call the clinician before engaging in the life-threatening
behavior—and are strongly reinforced for doing so. In DBT for adults, clients are
required to wait 24 hours after engaging in a life-threatening behavior to contact
the clinician; however, Miller, Rathus, & Linehan (2007) advise against this for ado-
lescents. Therefore, if the adolescent calls after engaging in a life-threatening behav-
ior, the clinician will need to assess for safety, and then terminate the call as quickly
as possible. If the client is hospitalized, she or he can have no contact with the clini-
cian during hospitalization, unless it is deemed necessary to help the client towards
successful skills use and discharge (this decision can be made with the assistance of
the consultation team).
The idea of intersession phone contact with clients may be anxiety inducing,
especially with clients who struggle with pervasive emotion dysregulation. Line-
han (1993) noted that the majority of skills coaching calls last ten minutes or less,
and are focused solely on helping the client identify skills he or she can use in the
moment. Be mindful of your personal boundaries—for example, not taking calls
after a certain time of night, as this will help prevent burnout (Ben-Porath, 2004).
You will also want to set up clear guidelines for phone coaching in the beginning
of treatment—not only should clients call before engaging in any life-threaten-
ing behaviors, but they should also be sure to call before their intensity of their
emotions gets too high, and they are unable to problem solve in the moment via
phone coaching (Ben-Porath, 2004). In fact, some clinicians require the client try
at least two skills before contacting the clinician for coaching (Ben-Porath and
Koons, 2005).
Regardless of the structure and limits surrounding phone coaching, it is still a large
responsibility for the clinician. Your job will be to help the client problem solve in
an efficient and supportive manner. At times this may be challenging, as the client
may digress into a discussion of the history of the current problem, or other topics
unrelated to problem-solving. When this happens, you will need to redirect the client
back to the current situation and skills use. If the client continues to be willful and
not engage in problem-solving behavior, then you will need to terminate the call.
Throughout these interactions, be mindful of voice tone and supportive responses.
When the phone call is appropriate, provide supportive responses. Conversely, if the
call is inappropriate, be “business like” and keep supportive responses to a minimum
(Ben-Porath, 2004).
In the event that the client does call you inappropriately (e.g., outside the guide-
lines you delineated at the beginning of treatment), you then need to engage the
client in a behavior chain analysis regarding this call during the next scheduled
session. This serves two purposes—it will help you and the client problem solve so
the behavior doesn’t happen again, and it can also help extinguish this behavior.
165
Clients often do not wish to engage in behavior chains, and would rather be dis-
cussing other things, and are therefore less likely to call you inappropriately again.
If inappropriate phone calls continue, you can decide to have the client take a
phone call “vacation”—this is to protect you from burnout as well as help the cli-
ent reflect on his or her behaviors before having the opportunity to call you again
(Linehan, 1993).
So, after all of this, you may still end up with a client on the phone who either
refuses to contract for safety, or has engaged in a self-harm behavior. First, you will
want to assess the client’s immediate safety. For self-harm, you will need to assess if
his or her injuries are life threatening. For suicidal thoughts, you will want to assess
if the client has a plan, means, or intent—if the client has two of these three factors,
then you will need to go focus more on ensuring the safety of the client as opposed
to skills coaching (Ben-Porath & Koons, 2005). If the client needs medical attention,
or needs to be hospitalized, then you will go through the steps to ensure his or her
safety; however again, you will need to minimize supportive responses and end the
call as soon as possible.
COMORBID DIAGNOSES
As you may imagine, when an adolescent is struggling with more than one psychiatric
disorder, the severity of his or her symptoms will increase. Up to 64% of adolescents
who have been diagnosed with major depressive disorder have also been diagnosed
with another psychiatric disorder. In one study, researchers found that as many as
40% of participants met criteria for at least three disorders (Small et al., 2008). The
most common comorbid diagnoses include anxiety and behavioral disorders, as well
as ADHD and substance use disorders (Avenevoli et al., 2015). Adolescents with
comorbid disorders are also less likely to experience positive treatment outcomes,
and spend more time in treatment than adolescents struggling with one disorder
(Andrews, Slade, & Issakidis, 2002).
DBT is a flexible treatment, and as result, it can be an extremely helpful approach if
you are working with a client who struggles with more than one diagnosis. By utiliz-
ing the DBT format of the hierarchical treatment targets, you will be able to organize
treatment goals, while emphasizing skills that will be the most helpful for the client’s
unique symptomology.
Assessment of Comorbid Diagnoses

In addition to diary cards, and the assessments we have listed in the outpatient chap-
ter for general program evaluation, you may also find the assessments outlined in
Chapter 12 helpful, as they target a variety of diagnoses. We have also included a
few other assessments you may find helpful not only assessing for the severity of the
client’s symptoms, but for evaluating the effectiveness of your program.
166
Comorbid Diagnoses
Kiddie-Sads-Present and Lifetime Version

The Kiddie-Sads-Present and Lifetime Version (K-SADS-PL; Kaufman, Birmaher,
Brent, & Rao, 1997) is a semi-structured interview, designed to assess for a variety
of mental health disorders. It is thorough, incorporates responses from parents and
children, and includes several steps, including supplemental diagnostic questionnaires
for specific diagnoses. It is also free for clinical use, and could be easily included in
the initial interview. However, due to the detail involved in completing this interview,
it can be time consuming, and the current available version has yet to be updated for
the changes in the DSM-5 (American Psychiatric Association, 2013).
Brief Symptom Inventory (BSI)

The Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983) is a shortened ver-
sion of the SCL-R-90 (Derogatis & Fitzpatrick, 2004) and can be used with adolescents
age 13 and older. It includes 53 self-report questions, and has a fairly short admin-
istration time of 8–10 minutes. It includes nine different symptom scales, as well as
three overall scales based on total symptoms and severity. This scale is flexible enough
for frequent use to assess treatment progress, and it encompasses a large variety of
symptoms and diagnoses.
Treatment Planning With Comorbid Diagnoses

Treatment planning for a client who has several diagnoses may seem overwhelming
at first. However, the hierarchical structure of DBT treatment targets facilitates the cli-
nician’s ability to easily identify the most important symptoms to focus on, regardless
of the diagnosis.
Life-Threatening Behaviors
Remember that decreasing life-threatening behaviors is considered the most crucial
treatment target in DBT. When an adolescent is struggling with multiple disorders, it
can be difficult to discern whether a behavior should be considered life threatening.
For example, driving fast is not considered a life-threatening behavior, unless the
adolescent is intentionally engaging in this behavior with the intent to harm him or
herself, or it is extreme to the point of acute danger (Miller et al., 2007). Or, as we
mentioned in Chapter 9, eating disordered behaviors are considered quality-of-life
interfering, unless a medical doctor deems them life threatening. To assess whether
a behavior should be considered life threatening, gather as much detail as you can
during the initial interview, and discuss the behavior with the adolescent as well
as parents and other family members. If you are still unable to discern whether a
behavior should be considered life threatening, consult with your DBT team, as other
clinicians can analyze the behavior objectively, help you identify any aspects you have
missed, or provide insight based on their experiences (Miller et al., 2007).
167
Therapy-Interfering Behaviors
Behaviors that interfere with the actual therapeutic process are likely similar for an ado-
lescent with several diagnoses as they are for those with just one. However, an adolescent
with comorbid diagnoses may exhibit more of these behaviors than other adolescents.
For example, an adolescent who has been diagnosed with ADHD in addition to depres-
sion may not only struggle with the behaviors related to symptoms of depression (e.g.,
missed appointments due to low energy) but behaviors related to ADHD (inability to
concentrate during session or group, disrupting others in group, etc.). Therapy-interfer-
ing behaviors may also be more severe, due to a higher level of emotion dysregulation.
For example, the adolescent may have more difficulty overcoming typical barriers to
treatment (e.g., using skills to overcome anxiety and attend group) due to the complex-
ity and severity of his or her emotions. Similarly, therapy-interfering behaviors that the
clinician or family members engage in may also be more severe. Comorbid diagnoses
often increase symptom severity, which increases the likelihood of clinician burnout, and
the likelihood of extreme behaviors by family members that can impede treatment (e.g.,
extreme disciplinary measures that limit the client’s ability to use skills effectively).
Quality-of-Life-Interfering Behaviors
Again, these are likely the same regardless of the number of diagnoses; however, the risk
of these behaviors being more frequent and more severe is higher with adolescents who
experience extreme and complex emotions. These behaviors may cover a broader array
of life situations and types of behaviors, and it may seem too difficult or overwhelming
to attempt to address all of them. We recommend working in conjunction with the ado-
lescent and his or her parents to find a few that are either the most extreme, or the most
concerning for all parties involved. Once the adolescent believes he or she is successfully
managing those specific behaviors, the therapist and adolescent can work together to
identify other important quality-of-life-interfering behaviors to target.
Increasing Behavioral Skills

One of the basic assumptions in DBT is that new skills must be learned and utilized in
all contexts (Linehan, 1993). Therefore, it may be helpful for you to spend more time
when discussing each skill, to be sure that you address all of the client’s symptoms.
For example, when reviewing diary cards, you could work with the client to identify
when he or she used a specific skill to manage a certain situation and behavior. By
using a dialectical approach that emphasizes flexibility, validation, and change, you
can help clients optimize their use of skills for home, school, and work.

In this chapter, we have discussed how to approach treatment planning for adolescents
who struggle with severe symptoms, either via multiple diagnoses or life-threatening
168
Comorbid Diagnoses
behaviors. One of the things I have always loved about DBT is that it provides me with
the tools to work with clients who struggle with a multitude of severe and life-threat-
ening symptoms. I find it empowering to not shy away from working with clients who
struggle with extreme pervasive emotion dysregulation, and I hope DBT can help you
feel empowered to do the same.
REFERENCES
American Psychiatric Association (APA) (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Andrews, G., Slade, T., & Issakidis, C. (2002). Deconstructing current comorbidity: Data from
the Australian national survey of mental health and well-being. The British Journal of Psy-
chiatry, 181(4), 306–314. doi:10.1192/bjp.181.4.306
Avenevoli, S., Swendsen, J., He, J., Burstein, M., & Merikangas, K. R. (2015). Major depres-
sion in the national comorbidity survey—adolescent supplement: Prevalence, correlates,
and treatment. Journal of the American Academy of Child & Adolescent Psychiatry, 54(1),
37–44. doi:10.1016/j.jaac.2014.10.010
Beck, A. T. & Steer, R. A. (1991). Beck Scale for suicide ideation manual. San Antonio, TX:
Psychological Corporation.
Ben-Porath, D. D. (2004). Intercession telephone contact with individuals diagnosed with
borderline personality disorder: Lessons from dialectical behavior therapy. Cognitive and
Behavioral Practice, 11(2), 222–230. doi:10.1016/S1077–7229(04)80033–6
Ben-Porath, D. D. & Koons, C. R. (2005). Telephone coaching in dialectical behavior ther-
apy: A decision-tree model for managing inter-session contact with clients. Cognitive and
Behavioral Practice, 12(4), 448–460. doi:10.1016/S1077-7229(05)80072–0
Centers for Disease Control and Prevention, National Center for Injury Prevention and Con-
trol. (2007). Web-Based Injury Statistics Query and Reporting System (WISQARS). Retrieved
from www.cdc.gov/ncipc/wisqars
Derogatis, L. R. & Fitzpatrick, M. (2004). The SCL-90-R, the Brief Symptom Inventory (BSI), and
the BSI-18. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning
and outcomes assessment: Instruments for adults (Vol. 3, 3rd ed., pp. 1–41). Mahwah, NJ:
Lawrence Erlbaum Associates Publishers.
Derogatis, L. R. & Melisaratos, N. (1983). The brief symptom inventory: An introductory report.
Psychological Medicine, 13(3), 595–605. doi:10.1017/S0033291700048017
Kaufman, J., Birmaher, B., Brent, D., & Rao, U. (1997). Schedule for affective disorders and
schizophrenia for school-age children-present and lifetime version (K-SADS-PL): Initial reli-
ability and validity data. Journal of the American Academy of Child & Adolescent Psychia-
try, 36(7), 980–988. doi:10.1097/00004583–199707000–00021
Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Nonsuicidal self-injury: What we know, and
what we need to know. The Canadian Journal of Psychiatry/La Revue Canadienne De Psy-
chiatrie, 59(11), 565–568.
Linehan, M. M., Comtois, K. A., Brown, M. Z., Heard, H. L., & Wagner, A. (2006). Suicide
Attempt Self-Injury Interview (SASII): Development, reliability, and validity of a scale to assess
suicide attempts and intentional self-injury. Psychological Assessment, 18(3), 303–312.
169
Lloyd-Richardson, E. E., Perrine, N., Dierker, L., & Kelley, M. L. (2007). Characteristics and
functions of non-suicidal self-injury in a community sample of adolescents. Psychological
Medicine, 8, 1183–1192.
Small, D. M., Simons, A. D., Yovanoff, P., Silva, S. G., Lewis, C. C., Murakami, J. L., & March, J.
(2008). Depressed adolescents and comorbid psychiatric disorders: Are there differences in
the presentation of depression? Journal of Abnormal Child Psychology, 36(7), 1015–1028.
doi:10.1007/s10802-008-9237-5
Whitlock, J., Muehlenkamp, J., Eckenrode, J., Purington, A., Baral Abrams, G., Barreira, P., &
Kress, V. (2013). Non-suicidal self-injury as a gateway to suicide in young adults. Journal of
Adolescent Health, 52(4), 486–492. doi:10.1016/j.jadohealth.2012.09.010
Yates, T. M., Tracy, A. J., & Luthar, S. S. (2008). Non-suicidal self-injury among “privileged”
youths: Longitudinal and cross-sectional approaches to developmental process. Journal of
Consulting and Clinical Psychology, 76(1), 52–62.
170
14
Summary and Conclusions
Our goal in this text was to provide you with usable materials and information to
adapt DBT for adolescents with a variety of different symptoms and in a variety of
settings. I hope that we have achieved that goal, and that this information can facil-
itate your implementation of a DBT program that fits the needs of your population
and your setting. There were a few recommendations that were consistent through-
out the book, and we will review a few of those here, as well as provide some addi-
tional thoughts and suggestions we have from personal experience. Finally, we will
highlight a variety of resources on DBT you will be able to use in conjunction with
this text.
MAJOR POINTS FOR CLINICIANS
Adaptation Considerations
Though DBT is flexible, and can be easily adapted, you also need to be aware of
your goals in treatment, and how DBT fits with those goals. For example, just
teaching the skills can certainly be helpful for clients, but it will likely not be as
effective as implementing all of the modes of treatment, and/or utilizing the thera-
pist strategies involved in the treatment (Linehan, 2015). If you wish to implement
DBT to elicit lasting and significant behavior change in your client, the current evi-
dence supports the use of full DBT. For example, I recently received an email from
a clinician asking for advice because she was using DBT with her clients and they
were having trouble applying the skills to daily life, and continued to engage in
problem behaviors. Upon further investigation, I realized she had taught the skills
in session, but she had not implemented any of the behavioral problem-solving,
or dialectical and commitment strategies that can be key in the success of DBT.
Once I explained the other facets of DBT that she had not included, she realized
she had not sufficiently educated herself on the treatment, and decided to seek
training before going further. I believe this may be a common occurrence, and
clinicians may teach a few skills from the manual and then experience disappoint-
ment when the results are not what they expected. At any rate, be sure that you
are intentional in how you implement DBT, and that you are well prepared before
going forward.
171
Treatment Commitment
We’ve talked a lot about commitment. At this point, I’m sure you’re tired of hearing
about it. Regardless, we’re going to mention it again. We have emphasized this point
repeatedly because Linehan (2015) and Rathus and Miller (2015) stress its impor-
tance—but I also believe that as clinicians, we can get caught up in the routine of
treatment, and sometimes forget about how important it is that the client makes a
conscious decision to take part in the treatment in the first place. For example, during
one of my DBT trainings, the trainers began to implement behavior chain analyses for
attendees who arrived to the training late. However, there was one major issue with
this—they had not asked us for a commitment to be on time, and as result, there
was a lot of dissent from the attendees that was then resolved by the group formally
committing to arriving on time.
A similar example involves a client I had when I first started implementing DBT
several years ago. I described the treatment and the process, and then explained the
diary card, gave it to her, and sent her on her way. However, week after week, she
returned without completing the diary card. I would insist on her completing the
diary card in session, which was upsetting for the client. It was a total disaster—she
hadn’t committed to the treatment, or made a commitment to complete the diary
cards. I had simply implemented it under the assumption that it was something she
was willing to do. As a result, this strained our relationship, and I had to start back at
the beginning to rebuild therapeutic trust.
Training
You will also need to be mindful of the level of training you will need to administer
DBT effectively. If you are only planning on incorporating some of the skills sporadi-
cally within your current treatment, you may not need as much training as if you were
implementing a full DBT program. Regardless, remember that there is a lot involved
in DBT; because of the level of complexity, it may take you awhile to get a full handle
on all of it. The more you immerse yourself in it, and use it in your daily life, the more
familiar you will become with the material, and the more effective you will be with
your clients.
Outcome Evaluation
Another aspect we’ve highlighted in each section is the importance of outcome eval-
uation. It is extremely important that you utilize a method of assessment to keep
track of your clients’ individual progress, as well as the effectiveness of your overall
program. Not only will this facilitate your ability to serve your clients in the best man-
ner possible, it will also help you gather data that you can use to provide evidence to
stakeholders of the effectiveness of your program. This data can also help you attain
reimbursement from third-party payers, and receive support from administrators. As
we have mentioned throughout the text, there are a lot of different ways to do this,
172
from simply using diary cards and counting frequency of problem behaviors, to for-
malized assessments with reports from parents, teachers, and adolescents. Nonethe-
less, be sure to assess all of the different outcome variables you wish to target.
CURRENT AND FUTURE DIRECTIONS IN DBT

Researchers continue to publish new information on the effectiveness of DBT. Though
the research is promising, there still is a lack of sufficient quality studies in DBT with
adolescents, and researchers continue to work to design and publish more research
on the topic. Recently published data has shown evidence of brain change related to
emotion regulation for patients who had received DBT treatment (Goodman et al.,
2014). Research continues on the dismantlement of DBT to identify if there are some
aspects of the treatment that are more effective than others. For example, one recent
study showed that a DBT skills group was more effective in reducing emotion dys-
regulation than an activities-based support group (Neacsiu, Eberle, Kramer, Wies-
mann, & Linehan, 2014).
Another area for future research is regarding the fidelity of the treatment in adap-
tations of DBT (McCay et al., 2016). DBT has been implemented in numerous settings
and with a variety of adaptations for adolescents. As a result, we need to give atten-
tion to the importance of the conformity of the treatment, and that clients are aware
any adaptions from traditional DBT in the treatment they are receiving.
Finally, researchers are continuing to take specific aspects of DBT and expand upon
them for use in different approaches—for example, therapy-interfering behaviors
(Chapman & Rosenthal, 2016). Researchers are also working to develop and eval-
uate new formalized assessments to measure aspects of DBT—for example, thera-
pist validation strategies (Carson-Wong & Rizvi, 2016; Stein, Hearon, Beard, Hsu, &
Björgvinsson, 2016).
OTHER RESOURCES ON DBT
Books
There are numerous books published on DBT, by a variety of researchers and clini-
cians. We will only list a few here that we are familiar with and believe will be helpful
for you.
Foundational Texts
Linehan, M. M. (2015). DBT® skills training handouts and worksheets (2nd ed.). New York,
NY: Guilford Press.
173
Press.
Texts for Specific Populations and Settings

Dimeff, L. A. & Koerner, K. (2007). Dialectical behavior therapy in clinical practice: Applications
across disorders and settings. New York, NY: Guilford Press.
Fruzzetti, A. E. (2006). The high conflict couple: A dialectical behavior therapy guide to finding
peace, intimacy, & validation. Oakland, CA: New Harbinger.
Harvey, P. & Rathbone, B. H. (2015). Parenting a teen who has intense emotions: DBT skills to
help your teen navigate emotional & behavioral challenges. Oakland, CA: New Harbinger.
Mazza, J. J., Dexter-Mazza, E. T., Miller, A. L., Rathus, J. H., Murphy, H. E., & Linehan, M. M.
(2016). DBT® skills in schools: Skills training for emotional problem solving for adolescents
(DBT STEPS-A). New York, NY: Guilford Press.
Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy for binge eating and
bulimia. New York, NY: Guilford Press.
Texts to Facilitate Implementation

Swenson, C. R. (2016). DBT® principles in action: Acceptance, change, and dialectics. New
Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. New York, NY: Guil-
ford Press.
Websites
There are several websites that provide information on DBT. However, there are a few
websites that you should be familiar with, especially if you wish to develop a program
or continue training in DBT.
• Behavioral Tech (www.behavioraltech.org) is an organization founded by Mar-

sha Linehan, and is the main DBT website that includes information on DBT, a
contact list for intensively trained DBT teams, and information for online and
in-person trainings. They also provide case consultation as needed. Though
there are definitely other resources for DBT trainings, this provides a wide variety
of options, including the intensive ten-day training for teams, which is consid-
ered the gold standard for DBT training.
• DBT-Linehan Board of Certification (www.dbt-lbc.org) is the website for infor-
mation regarding becoming a Linehan Board-Certified DBT clinician. The process
to become a Certified DBT clinician includes attaining a specified number of
hours of training, sitting for a written test, and then submitting videotapes of
counseling sessions to provide verification that you understand the material, and
174
that you are able to apply it. Though certification is not necessary to provide DBT
services, it does increase your credibility in the field, and will enable you to say
that you are officially certified. Be wary of other websites that claim to provide
DBT certification, as they are not affiliated with Behavioral Tech, and are not
considered the official certification.
• www.dbtselfhelp.com is a website that is managed by former or current partici-
pants in DBT treatment. Though it is an informal website, it does provide useful
resources, including a format to make your own diary cards.
Smart Phone Applications

With the increase in technology use, especially with adolescents, smart phone appli-
cations (apps) may be a perfect venue to increase skills use and treatment compli-
ance. There are numerous options, including diary card apps that can be personalized
to the client, and formatted into a PDF to print and bring to session. There are also
apps that include the different skills and practice exercises. Be sure to verify all of the
aspects of any smart phone application before suggesting it to your client.
REFERENCES
Carson-Wong, A. & Rizvi, S. (2016). Reliability and validity of the DBT-VLCS: A measure to
code validation strategies in dialectical behavior therapy sessions. Psychotherapy Research,
26(3), 332–341. doi:10.1080/10503307.2014.966347
Chapman, A. L. & Rosenthal, M. Z. (2016). Managing therapy-interfering behavior: Strategies
from dialectical behavior therapy. Washington, DC: American Psychological Association.
doi:10.1037/14752–000
Goodman, M., Carpenter, D., Tang, C. Y., Goldstein, K. E., Avedon, J., Fernandez, N., . . .
Hazlett, E. A. (2014). Dialectical behavior therapy alters emotion regulation and amygdala
activity in patients with borderline personality disorder. Journal of Psychiatric Research, 57,
108–116. doi:10.1016/j.jpsychires.2014.06.020
McCay, E., Carter, C., Aiello, A., Quesnel, S., Howes, C., & Johansson, B. (2016). Toward treat-
ment integrity: Developing an approach to measure the treatment integrity of a dialectical
behavior therapy intervention with homeless youth in the community. Archives of Psychiat-
ric Nursing, 30(5), 568–574. doi:10.1016/j.apnu.2016.04.001
Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan, M. M. (2014). Dialectical
behavior therapy skills for transdiagnostic emotion dysregulation: A pilot randomized con-
trolled trial. Behaviour Research and Therapy, 5940–5951. doi:10.1016/j.brat.2014.05.005
Press.
Stein, A. T., Hearon, B. A., Beard, C., Hsu, K. J., & Björgvinsson, T. (2016). Properties of the dia-
lectical behavior therapy ways of coping checklist in a diagnostically diverse partial hospital
sample. Journal of Clinical Psychology, 72(1), 49–57. doi:10.1002/jclp.22226
175
Handout 1.1
Biosocial Theory
Invalidating Biological Vulnerability

Environment
• High Emotional
• Stress-Filled Home Sensitivity
• High Emotional
• Indiscriminately Rejects
Reactivity
Private Experience
• Slow Return to Emotional
• Punishes Emotional Baseline
Displays While
Intermittently Reinforcing • Biological Predisposition
Emotional Escalation
• Oversimpliies Ease of
Problem-Solving and
Meeting Goals
Emotional and Behavioral Dysregulation
• Doesn’t Know How to Express Emotions Appropriately

• Negative Coping Techniques Such as Substance Abuse, Eating
Disorders, and Self-Harm
Source: Adapted with permission from Linehan, M. M. (2015). DBT® skills training manual (2nd ed.).
©2018, Dialectical Behavior Therapy With Adolescents, K. Michelle Hunnicutt Hollenbaugh and
Michael S. Lewis, Routledge
Handout 1.2
Diary Card
Name: Beginning Date:
Targets Emotions
Self-
Date
Harm
Care
Suicidal
Ideations
Phone
Consult
Happiness
Anger
Fear
Shame
Hurt
Sadness
Urge Action 0-5 Y/N Urge Action Urge Action Urge Action Urge Action 0-5 0-5 0-5 0-5 0-5 0-5 0-5
Tu
Th
Su
Suicidal Ideation: 0 – No Thoughts 1 – Some Thoughts 2 – Intense Thoughts 3 - Very Intense 4 - Making a Plan 5 – Ready to Enact a Plan
Source: Adapted with permission from Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). New York, NY: Guilford
Press.
©2018, Dialectical Behavior Therapy With Adolescents, K. Michelle Hunnicutt Hollenbaugh and Michael S. Lewis, Routledge
Handout 1.3
Diary Card 2
Name:
Name Beginning Date:
Targets Emotions
Dialectical Burning Building

Active Denial Urge Suring
Abstinence Bridges Bridges
Date
Care
Cravings
Anger
Fear
Shame
Hurt
Sadness
Thought Used Urge Action Urge Action Urge Action Urge Action 0-5 0-5 0-5 0-5 0-5 0-5 0-5
Tu
Th
Su
Source: Adapted with permission from Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). New York, NY: Guilford Press.
Handout 1.4
Diary Card 3
Name: Beginning Date:
Targets Emotions
Act of Aggressive
Re-offending
Rebellion Behaviors
Date
Care
Violent
Anger
Fear
Shame
Hurt
Sadness
Thought Used Urge Action Urge Action Urge Action Urge Action 0-5 0-5 0-5 0-5 0-5 0-5 0-5
Tu
Th
Source: Adapted with permission from Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). New York, NY: Guilford Press.
Handout 1.5
Daily Diary Card

Name:
Skill Usage Emotions
Primary Target:
_______________
Date
_______________
Care
Suicidal
Ideations
Participation
Happiness
Anger
Fear
Shame
Hurt
Sadness
Urge Action 0-5 Y/N Thought Use Thoughts Use Thought Use Thought Use 0-5 0-5 0-5 0-5 0-5 0-5 0-5
9a
10a
11a
12p
1p
2p
3p
4p
5p
6p
7p
8p
9p
10p
11p
Source: Adapted with permission from Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). New York, NY:
Guilford Press.
Handout 1.6
Source: Adapted with permission from Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). New York,
NY: Guilford Press.
Handout 1.7
Source: Adapted with permission from Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). New York, NY:
Guilford Press.
Handout 2.1
Handout 3.1
Handout 3.2
Treatment Team Contacts

Below is a list of your treatment team members, contact information, and why you would contact them
Team Leader: ____________________________________________________ Psychiatrist: _____________________________________________________
Phone Number: __________________________________________________ Phone Number: _________________________________________________
Meeting Times: __________________________________________________ Meeting Times: _________________________________________________
Contact If: ________________________________________________________ Contact If: _______________________________________________________
Skills Trainer: ____________________________________________________ Additional Member: ____________________________________________
Primary Clinician: _______________________________________________ Additional Member: ____________________________________________
Case Manager: ___________________________________________________ Additional Member: ____________________________________________
Contact If: ________________________________________________________ Contact If: ______________________________________________________
Physician: ________________________________________________________ Additional Member: ____________________________________________
Handout 3.3
Weekly Medication Management

Name:
These are the medications I’m currently taking:
Name Dosage Time(s) Taken Circle Days Taken
M T W Th F S Su
M T W Th F S Su
M T W Th F S Su
M T W Th F S Su
M T W Th F S Su
M T W Th F S Su
Note here any differences you’re experiencing with thinking, mood, or side effects that seem related to your medication:
Handout 3.4
Handout 3.5
Handout 3.6
Handout 3.7
Handout 4.1
Handout 4.2
Source: Adapted with permission from Rathus, J. H. & Miller, A. L. (2015). DBT® skills manual for ado-
lescents. New York, NY: Guilford Press.
Handout 4.3
Interpersonal Effectiveness Myths

Challenge these common myths we tell use when worried about interacting with others
Myth: People are thinking the worst about me

Challenge:
Myth: I can’t take it if others disagree with me

Challenge:
Myth: If I ask for something, I’ll look weak

Challenge:
Myth: People only look out for themselves, so I should too

Challenge:
Myth: Saying no to someone is selish and greedy

Challenge:
Myth: It doesn't make a difference what I say or do, so I just won’t care
Challenge:
Myth: If someone is kind to me it’s because they want something

Challenge:
Myth: I don’t deserve compliments or other’s attention

Challenge:
Myth: This is the worst possible thing that could have happened
Challenge:
Myth: Come up with your own example:

Challenge:
Handout 4.4
Handout 4.5
Source: Adapted with permission from Linehan, M.M. (2015) DBT® Skills Handouts and Worksheets.
New York: Guilford Press.
Handout 4.6
Handout 4.7
Handout 4.8
Acting the Opposite

You’ve heard of “fake it ‘til you make it”—sometimes that’s how our emotions work too. If we act the opposite to how we feel, often
our emotional state will change for real. Our brain works in funny ways, and the more we believe something to be true the more it
will be true.
What does the current emotion (anger, hurt, apathy, etc.) feel like to you?
What would the opposite look like?
How do you see this working?
After trying it, how did it work?
Handout 4.9
Cope Ahead
Instead of waiting for a situation to come up and igure out what to do, think ahead and igure out how you might
best handle it.
Think of a upcoming situation you think you might have dif iculty handling or will prompt strong emotions. Be speci ic.
What skills would help out in this particular situation and why?
Imagine yourself in the situation NOT using the skill. How does it go?
Imagine yourself in the situation using the skill. How does it go?
Now practice mindfully through the situation until you feel prepared!
Handout 4.10
Radical Acceptance
Radical acceptance means fully taking in the reality of the situation. That the facts are the
facts even if you don’t care for them. What is the reality of the current situation?
Acceptance doesn't mean approval—you don't have to like it, or think it is fair.
Acceptance is a way of understanding the current situation.
What are the emotions you feel?
Changing the future requires accepting the present.
What are the changes you can foresee yourself making and what are the current hurdles
you must accept to make this change?
Handout 4.11
Handout 4.12

Move yourself beyond thinking in extremes—instead view yourself as walking steadily between two seemingly opposite ideas.
Below are some examples as well as an opportunity to think of some of your own. Move from either/or to both/and
Autonomy Dependence
Passive Aggressive
Conidence Insecurity
Emotional Rational
Anger Love
Image © Shutterstock
Handout 4.13
Validation
Validation of Others: Acknowledge and let the other person know that you recognize his or her thoughts and feelings
and they are clear to you. Validation does not mean agreement; rather instead it lets a person know that you’ve
heard them and their thoughts and feelings are important to you. You can do this through eye contact, nodding
your head, not being critical, and in general showing them respect.
Self-Validation: Acknowledge your own thoughts and feelings as real, accurate, and clear. You can do this by
being mindful of your thoughts and emotions in a situation and naming them to yourself and others. Don’t judge
them or assign them as “stupid” but simply notice them and let them be.
What did you do to Validate Others today?
What did you do to Validate Yourself today?
How would you grade yourself on validation today? (1—needs a lot of work—10—did great):
How can you improve tomorrow?
Handout 4.14
Changing Behavior
There are four primary ways to modify behavior: Reinforcement, Punishment, Extinction, and Shaping.
• Reinforcement: using consequences (positive or negative) to increase a desired behavior. Positive

reinforcement uses a reward such as praise or a treat while negative reinforcement removes an unwanted
experience such as stopping an annoying noise.
• Punishment: an action that attempts to decrease an unwanted behavior. Examples of punishment could
include being grounded for misbehaving or getting a poor grade on a test after not studying.
• Extinction: a decrease of a behavior because reinforcement is no longer provided. For example, you clean
your room because you get $5 for doing so. When you stop getting paid, you stop cleaning the room.
• Shaping: reinforcing small behaviors that are leading to the desired behavior. We use shaping to teach our
pets how to do tricks by giving them a treat when they get close to the desired behavior and increase it as
they get it more and more correct.
Which of these do you think is most effective and why?
Think of an example when one of these was used effectively for you.
Think of a behavior you want to increase or decrease—how can you use one of these methods to accomplish it?
Handout 4.15
Group Orientation
Working with others in a group setting provides you with feedback, support, and a connection with
others dealing with similar concerns as yours. It is normal to feel apprehensive or uneasy, have
concerns and questions about how this will work, or worry if it will even work at all. Rest assured this is
completely expected. In fact, since most others are feeling the same way it can be helpful to address
these concerns in group.
Groups come in different sizes, for different purposes, and have different topics but what remains
consistent is than the more you put into the group process the more you’ll get out of it. Some days will be
more dificult than others but if you keep coming and allow yourself to be honest, you’ll get out of it
what you need.
To help you get the most of the experience we recommend the following guidelines
Be Patient: The group process can take time and there will be sessions that are frustrating. Commit to
attending ive group sessions before passing judgment on how useful this is for you
.
Be Honest: Be open with others and allow yourself to be vulnerable at times.
Be Present: Both physically (as in on time for group) and psychologically (as in aware and attentive)
during group time.
Offer Support: Give feedback and encouragement to other group members when you see
opportunities. Giving support is not the same as advice—instead of making suggestions, allow members
to decide what’s best for them while you cheerlead.
Test With New Behaviors: Group is a great place to try new techniques ina safe environment.
Be open to trying and getting feedback from others on how it went. It’ll make it easier to try it later.
Conidentiality: What is said in group stays in group. We need to be able to trust one another with our
information. Don’t share anything with anyone else outside of group and only talk about group topics
during group time.
Respect: Be sensitive to others. No name calling, poking fun, or in general picking on other group
members.
Focus on the Topic: Therapy works best when we can stay on topic and explore what that entire topic
has to offer. It can be easy to get diverted or think of another topic. Hold those comments for later or
ask a group facilitator when it would be appropriate to bring it up.
Be Yourself: Relax and have fun with the process. Let us get to know the real you and we’ll do the
same.
Handout 4.16
Group Rules
In order for the group to work well together and get the most out of this experience, we
ask that you follow the following rules and guidelines. Please hold yourself and others
accountable to these rules.
Conidentiality: Information and stories shared here are not to be discussed

outside of group. If it’s said here, leave it here.
Punctuality: Be mindful of the work members are doing in group and how
coming late can disrupt that process. If you are late alert a team member and
we can insert you when it is appropriate to do so.
Participation: All members help others and your feedback can be invaluable
to the others. Showing care and support is the reason group
therapy works.
Respect: Be kind to other members’ thoughts, ideas, and feelings. Group is a

place of vulnerability and we want to provide a safe space for all members to
share without fear of being put down. This also includes members who are
not present.
Complete Assignments: Homework will be discussed in group and it is

disruptive to have to work around a member who hasn’t done the work.
Socializing Outside of Group: Your irst duty is to the group and becoming
friends outside of the group confuses the boundaries of group relationships
and can be disruptive to the group process.
Sobriety: Coming to group intoxicated moves the focus unfairly to you and
takes away from the progression of the group as a whole.
“I” Statements: Speak from your own point of view and own your thoughts,
feelings, and behaviors.
Handout 5.1
Handout 5.2
Source: Adapted with permission from Linehan, M. M. (2015). DBT® skills handouts and worksheets.
Handout 5.3
Source: Adapted with permission from Fruzzetti, A. E., Santisteban, D. A., & Hoffman, P. D. (2007). Dialectical
behavior therapy with families. In L. A. Dimeff, K. Koerner (Eds.), Dialectical behavior therapy in clinical practice:
Handout 6.1
Paral Hospital Teen Daily Goal Sheet

Name: _____________________________________________________________ Day: ________________________ Date: ______/______/_______
PROGRAM TARGET GOAL: _____________________________________________________________________________________________________________
PLAN TO REACH GOAL: _________________________________________________________________________________________________________________
PATIENT’S SUMMARY OF DAY:

1 2 3 4 5
* Commitment absent or weak * Some willfulness in response * Both willfulness and * Generally willing and * Willing, asks for help
* Willful in response to to coaching and skill use willingness present responsive to coaching/ * Very effective participation
coaching and skill use * Little or inconsistent * Tries some skills and skill use and solution * Makes effort to apply
* Little participation participation makes some effort analysis skills to problems
* Therapy-destroying and/ * Some therapy-interfering to participate * Good participation * Follows up on solutions
or persistent therapy- behavior * Few or no therapy- * Sometimes asks for help * Strong commitment
interfering behavior * Some commitment present interfering behavior * Committed to goals to reaching goals
* Adequate commitment
PROGRAM POINTS:
1 2 3 4 5
(0–14 Points Earned) (15–18 Points Earned) (19–22 Points Earned) (23–26 Points Earned) (27–28 Points Earned)
STAFF COMMENTS (Behavior, Assignments, Information Attached, etc.) TIBS: _______________________
_________________________________________________________________________________________________________
________________________________________________________________________________________________________ _
MEDICATION TAKEN AT DAYBREAK: _________________________________________________________ STAFF SIGNATURE:__________________________________________________
HOME TARGET GOAL: ________________________________________________________________________________________________________________________
PLAN TO REACH GOAL:_______________________________________________________________________________________________________________________
Patient Summary: I am up to date on Diary Card: _____ YES _____ NO

Completed my DBT Homework: _____ YES _____ NO
USED SKILLS:
1 2 3 4 5 6
Didn’t think about Crossed my mind Tried to use them Tried to use them Tried to use them Used automatically
them but didn’t use them but didn’t help and they helped some and they helped and they helped
PATIENT’S SUMMARY OF AFTERNOON AND NIGHT:

1 2 3 4 5
*Unpleasant *Unpleasant at times *Some self-motivation * Fairly self motivated *Demonstrated initiative
*Poorly self motivated *Dificult to motivate *Responded to adult instructi on *Fairly engaged *Excellent attitude
*Disrespectful *Willful * Moderate self control *Used/taught skills
*Did not follow *Minimal compliance with *Improving attitude
adult instruction adult instruction
MEDICATION TAKEN AT HOME WAS MEDICATION TAKEN AS DIRECTED?
Name of Med.(s) / Time Given / Dosage (mg’s)
1.___________________/____________/____________ Yes No (Why)____________________________

2.___________________/____________/____________ Yes No (Why)____________________________
3.___________________/____________/____________ Yes No (Why)____________________________
Parent Comment: remember to practice validation and a non-judgmental attitude with suggestions for problem-solving
___________________________________________________________________________________________________________________________________________________
Signed:_____________________________________________________________
Handout 6.2
Missing Links Analysis

Name: ____________________________________ Date: _____________ Missing Behavior: __________________________________________________
To understand missing effective behaviors, do a missing link analysis

Use this sheet to irst igure out what got in the way of doing things you needed or hoped to do or things you agreed to that others expected you to do.
Then use that information to problem solve so that you will be more likely to do what is needed, hoped, or expected next time
1: Did I know what effective behavior was needed or expected? YES _____ NO _____
If NO to question #1, DESCRIBE what got in the way of knowing:
DESCRIBE problem-solving:
STOP
2: If YES to question #1, was I willing to do what was needed? YES _____ NO _____
If NO to question #2, DESCRIBE what got in the way of wanting to do what was needed
DESCRIBE problem-solving:
STOP
3: If YES to question #2, did thoughts of doing what was needed or expected ever enter my mind? YES _____ NO _____
If NO to question #3, DESCRIBE problem solving:
STOP
4. If YES to question #3, Describe what got in the way of doing what was needed or expected right away:
DESCRIBE problem solving:
STOP
Source: Used with permission from Linehan, M. M. (2015). DBT® skills handouts and worksheets. New
Handout 6.3
Handout 6.4
Handout 6.5
Top 10 Thinking Errors

All-or-Nothing Thinking: Thinking of things in absolute terms (always, every, never). If something isn’t 100% then it is a
total failure. To Defeat: Understand the only absolute is that there are no absolutes. Ask yourself disputingquestions such
as “Can I think of a time when it was NOT that way?” or ind exceptions to the thinking. Investigate best and worst case
scenarios to test the validity of thinking.
Overgeneralization: Taking isolated situations and using them to make wide-sweeping generalizations. To Defeat:
Understand that the past does not predict the future—that one event happened does not necessarily mean it will always
happen. Keep things in perspective of their own unique situations.
Mental Filter: Focusing exclusively on certain, usually negative, aspects of something while ignoring the rest (usually
positive). This often includes generalizing the negative (“I’m stupid”) and discounting the positive. To Defeat: Train
yourself to look for the positive in most any situation. Counter negative comments or thoughts with positive ones to help
maintain balance.
Disqualifying the Positive: Continually “shooting down” positive experiences for arbitrary reasons. This way you
maintain a negative belief that is contradicted by your everyday experiences. Basically, the good stuff doesn’t count
because everything else is so miserable. To Defeat: Make a list of your personal strengths and accomplishments and
remind yourself of them often. Accept compliments from others with a simple “thank you.”
Jumping to Conclusions: Assuming something negative when there is no actual evidence to support it. Assumingthe
intentions of others (mind reading), you conclude that someone is reactingnegatively to you without bothering to check it
out. In another instance you anticipate things will turn out poorly (fortune telling) and assume this is a foregone
conclusion before the event. To Defeat: Ask yourself what evidence you have to support your conclusions and if they are
grounded in truth. Are there other possible explanations that you haven’t considered? Ask for clariication before
assuming someone else’s intentions, thoughts, or feelings. If all else fails, simply let go of the thought and conclude you
don’t have enough evidence to hold on to it.
Magniication and Minimization: Exaggerating negative and understating positives. Often positive characteristics of other
people are exaggerated and negatives understated. Focusing on the worst possible outcome (catastrophizing), however
unlikely, prohibits you from considering other outcomes and that you’re simply “doomed.” To Defeat: Ask yourself
how/why this is so bad/good/much/little/etc. and compared to what exactly. Attempt to scale your thoughts and match
your response to given situation.
Emotional Reasoning: Making decisions and arguments based on how you feel rather than objective reality. Becoming
blinded by feelings and reacting to it as facts. To Defeat: Ask yourself what is it about the present situation that
produces the feelings and what thoughts are behind them. What is the nature of these thoughts—do they perhaps fall into
one of these other thinking error categories?
Shoulding: Focusing on what youbelieve you, others, and the world ought to do/not do.Applying expectations that go
against the objective reality of the situation. Replacing goals and objectives with expectations, which lead to guilt and
shame when they aren’t met. To Defeat: Remove the word should/ought/must from your vocabulary and replace them
with goal-oriented language that better represents the rational reality.
Labeling and Mislabeling: Explaining by naming rather than describing a speciic behavior. Assigning a label to someone
or yourself that puts them/you in an absolute, unalterable negative light. This is a logic-level error by which we make a leap
from a behavior/action to an identity (he was rude to me . . . therefore he’s a jerk). To Defeat: Specify thoughts and
comments to speciic situations and avoid broad, wide sweeping statements or names. Remember we are not deined by
our behaviors and can change.
Personalization and Blame: Occurring when you hold yourself personally accountable for an event that isn’t entirety
in your control. To Defeat: Ask yourself how speciically you are to blame and what portion of fault can you own.
Is this a situation you can resolve and/or change in the future?
lescents. New York, NY: Guilford Press; Linehan, M. M. (2015). DBT® skills handouts and worksheets.
Handout 6.6
B.E.A.T.
Learning to solve problems effectively involves implementing new skills. Using the B.E.A.T.
skill is an easy way to assess, break down, and defeat any problem.
B—Behavioral: Identify problem behaviors to decrease and skillful behaviors to increase

• Decrease avoidance behaviors
• Eliminate substance use
• Eliminate emotional and vocational outbursts
• Decrease family power struggles and conlict
• Eliminate self-injury
E—Educational: Learn a proven set of problem solving skills and acceptance strategies
• Mindfulness skills—increase awareness of emotions and tolerate destructive urges
• Distress tolerance skills—increase skills to get through dificult situations without making them worse
• Emotional regulations skills—increase skills to identify and change emotions
• Interpersonal effectiveness skills—increase skills to effectively ask for what you want, keep relationships positive, and
accept “no” when needed
• Middle path skills—increase skills to solve family problems
A—Action Oriented: Learning skills involves practice

• Rehearse skills in new situations
• Seek guidance when stuck
• Allow yourself to try and fail
• Acknowledge your successes
T—Teamwork: Partner with your therapist and treatment team to identify problems that you want to solve
and goals you want to reach
• Commit to your treatment
• Ask for help
• Review options with therapist
Handout 6.7
Understanding Goals and Problems

What is a goal? Anything you want to achieve or accomplish. It can be about school, work, family, or friends; it can be about
activities, skills you want to acquire, or places you’d like to visit. In other words, the sky is the limit. Write down as many goals as you
have or that come into your mind
What is a problem? Usually a problem is something that will get in the way of reaching your goals. A problem can be a feeling
(anger, sadness, fear, etc.), a behavior (avoiding, arguing, hiding, attaching, etc.), a thought (self-doubt, worthlessness, wondering what
friends think, family concerns, etc.), a bodily sensation (tight muscles, stomach pains, rapid heart rate,etc.), or a situation (family
changes, conlicts with family or friends).
What are the problems that are challenging you right now?
Which of these problems feels the most important for you to solve and why?
Which of these problems feels the easiest for you to solve and why?
Which of these problems feels the most dificult for you to solve and why?
Handout 6.8
Handout 6.9
Partial Hospital Behavioral Expectations and

Rules of Conduct
Therapy Enhancing:
1. Report any thoughts to self-harm, harm others, or run away to staff or parent.
2. Attend program every day and arrive on time.
3. Ask for help when you need it.
4. Be willing to try out behavioral suggestions.
5. Accept no for an answer without argument or complaint, verbal or nonverbal.
6. Follow the rules and guidelines for the program the irst time instruction is given.
7. Practice mindfulness every day.
8. Complete Diary Card every day.
Therapy Destroying:
1. Possessing dangerous contraband.
2. Leaving the building without staff permission.
3. Refusal to accept consequences.
4. Physical aggression.
5. Verbally abusive, hostile, or threatening behavior towards others or yourself.
Therapy Interfering:
1. Not following adult instructions the irst time.
2. SUBGROUPING: Contact between patients after program hours. This also includes exchanging notes, phone
numbers, e-mails, addresses, screen names, social media handles, etc.
3. Being late. If you are late, you need a dated signed note from your parent stating why you are late.
4. Not bringing a completed signed goal sheet and/or educational folder from home. It is expected that both
are brought in complete and signed every day.
5. Not keeping your hands to yourself.
6. Not treating peers, staff, and yourself with respect. (No put downs, disrespectful behavior, critical
comments, etc.)
7. Whispering, giving the appearance of whispering, or nonverbal communication.
8. Communication with students in TIBS or on protocol.
9. Talking about movies, TV, music, violence, weapons, illegal substances, or any other topic that is overtly and
predominantly dark, aggressive, or antisocial.
10. Going to any other area of the program without staff approval.
11. Not bringing your lunch every day. If you do not bring a lunch you must sit in silent lunch.
12. Having any personal electronic device during program hours. Any personal electronic devices must be
given to staff every morning before or during group.
Ten General Guidelines and Rules:

1. Bring all materials and supplies to class and have them labeled with your full name.
2. In the classroom and speciied groups, raise your hand for staff permission before speaking.
3. Do not write in or on any program property.
4. Put your name and date on your lunch every day.
5. Do not share your lunch without staff approval.
6. To purchase a soda or snack, you must bring a nutritional lunch approved by staff.
7. You may not borrow or exchange money from peers or staff.
8. Backpacks and purses are not allowed in the program.
9. Students driving to the program must give keys to staff upon arrival.
10. Sign in and out of the bathroom with your name and the time you are signing in.
I understand the above rules and agree to follow them. I also understand that if the rules are not followed, consequences will
occur.
_______________________________________________ _______________________________________________
Handout 7.1
Handout 7.2
Handout 9.1
Source: Adapted with permission from Wisniewski, L., Safer, D., & Chen, E. (2007). Dialectical behavior
therapy and eating disorders. In L. A. Dimeff, K. Koerner (Eds.), Dialectical behavior therapy in clinical
practice: Applications across disorders and settings (pp. 174–221). New York, NY: Guilford Press.
Handout 9.2
Handout 9.3
Source: Adapted with permission from McMain, S., Sayrs, J. R., Dimeff, L. A., & Linehan, M. M. (2007).
Dialectical behavior therapy for individuals with borderline personality disorder and substance depen-
dence. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications
Handout 9.4
Handout 9.5
Handout 9.6
Food Log
Meal Contents Emotions Notes
Breakfast
Lunch
Dinner
Date:
Drinks
Other
Breakfast
Lunch
Dinner
Date:
Drinks
Other
Breakfast
Lunch
Dinner
Date:
Drinks
Other
Breakfast
Lunch
Dinner
Date:
Drinks
Other
Breakfast
Lunch
Dinner
Date:
Drinks
Other
Breakfast
Lunch
Dinner
Date:
Drinks
Other
Handout 10.1
Handout 10.2
Source: Adapted with permission from McCann, R. A., Ball, E. M., & Ivanoff, A. (2000). DBT with an
inpatient forensic population: The CMHIP forensic model. Cognitive and Behavioral Practice, 7(4),
447–456. doi:10.1016/S1077-7229(00)80056-5
Handout 11.1
dence. In L. A. Dimeff, K. Koerner, L. A. Dimeff, K. Koerner (Eds.), Dialectical behavior therapy in clinical
practice: Applications across disorders and settings (pp. 145–173). New York, NY, US: Guilford Press.
Handout 11.2
Apparently Irrelevant Behaviors
It can be quite easy to overlook the thoughts, feelings, and behaviors that lead to negative and harmful
consequences such as eating disorders, crime, and substance abuse. Just like we can’t go from A to Z without
going through LMNO. Identify below the people, places, and things that while they don’t seem problematic
at the time can lead to the behaviors you’re trying to avoid.
A. ___________________________________________ N. ___________________________________________
B. ___________________________________________ O. ___________________________________________
C. ___________________________________________ P. ___________________________________________
D. ___________________________________________ Q. ___________________________________________
E. ___________________________________________ R. ___________________________________________
F. ___________________________________________ S. ___________________________________________
G. ___________________________________________ T. ___________________________________________
H. ___________________________________________ U. ___________________________________________
I. ___________________________________________ V. ___________________________________________
J. ___________________________________________ W. ___________________________________________
K. ___________________________________________ X. ___________________________________________
L. ___________________________________________ Y. ___________________________________________
M. ___________________________________________ Z. Problem Behavior
Handout 11.3
Handout 11.4
dence. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behavior therapy in clinical practice: Applications
Index
Page numbers in italics indicate figures and in bold indicate tables on the corresponding pages.
12-step support groups 141 Beck Depression Inventory (BDI) 157

24-hour skills coaching 8 Beck Scale of Suicide Ideation 162
behavioral contingencies and expectations
absence of alternatives 23 – 24 in partial hospital program settings
abstinence, dialectical 115, 138 – 139, 222 77 – 78
acting the opposite skill 44, 151, 154, 199 behavioral skills, increasing of 16; with
active passivity vs. apparent competence 17 comorbid diagnoses 168
acts of kindness 130, 229 Behavioral Tech 20, 50, 174
adaptive denial 140 – 141, 233 behavior chain analysis 182; for life-
addict mind 138 threatening behaviors 163 – 164
administrators in partial hospital program Behavior Chain Analysis (BCA) 11
settings 78 behaviorism 46
admissions director in partial hospital Ben-Porath, D. D. 112 – 113
program settings 79 – 80 billing 50 – 51
Adolescent Family Life Satisfaction index 61 binge eating disorder 109; see also eating
Alcoholics Anonymous 141 disorders
Allen, J. P. 68 biosocial theory 3 – 4, 177; conduct disorder
alternate rebellion 116, 140, 226 and criminal behaviors and 125, 126;
American Association for Ambulatory eating disorders and 111 – 112
Behavioral Healthcare (AAABH) 63 bipolar disorder 154 – 156
ancillary modes 9 borderline personality disorder (BPD) 1
ancillary team members 33; therapy- Brief Symptom Inventory (BSI) 167
interfering behaviors by 35 building bridges 140, 232
Andolfi, M. 72 bulimia 109; see also eating disorders
Angelo, C. 72 burning bridges 115, 140, 223
anger management 130 – 131 burnout, clinician 16
Antonishak, J. 68
anxiety 149 – 151 care, continuity of 33 – 34
apparent compliance vs. active defiance 114 case management strategies 12
apparently irrelevant behaviors case managers 32; in partial hospital
139 – 140, 231 program settings 80
assessment: of comorbid diagnoses 166; changing behavior 205
initial diagnostic 24; overall program cheerleading 24
evaluation 25; of treatment outcomes Child Behavior Checklist 134
24 – 25 clean mind 138
attrition 49 – 50 clear mind 138, 230
client report 191
Ball, E. M. 130 clinical directors in partial hospital program
B.E.A.T. 216 settings 78 – 79
Beck Anxiety Inventory (BAI) 157 clinician interfering behaviors 16
235
Index
clinicians: burnout 16; inpatient 88; major dialectical abstinence 115, 138 – 139, 222
points for 171 – 173; outpatient 87 – 88; Dialectical Behavior Therapy (DBT):
primary 31; see also treatment team ancillary modes 9; for anxiety 149 – 151;
coding scale, validating and invalidating assessment in 24 – 25; for bipolar disorder
behaviors 60 – 61 154 – 156; commitment strategies
Cognitive Behavioral Therapy (CBT) 1, 152 22 – 24, 184; for comorbid diagnoses
Cognitive-Behavioral Treatment of Borderline 166 – 168; for conduct disorder (see
Personality Disorder 10 conduct disorder, probation, and juvenile
commitment strategies 22 – 24, 184 detention settings); consultation group
commitment to treatment 172; in conduct 9; current and future directions in 173;
disorder, probation, and juvenile for depression 152 – 154; dialectics
detention settings 134 – 135 and 4 – 5; difference of 1 – 2; for eating
communication problems 35 – 36 disorders (see eating disorders); in family
community mental health (CMH) settings counseling (see family counseling);
39 – 40 homework 214; implementation
comorbid diagnoses 166 – 168 (see implementation); individual
conduct disorder, probation, and juvenile sessions 8 – 9; information sheet 189;
detention settings 123 – 124; adaptations in inpatient settings (see inpatient
to DBT for 128 – 131; additional treatment settings); intersession skills coaching 8;
team members and roles 128; biosocial for life-threatening behaviors 14, 126,
model of 125, 126; challenges and 161 – 166; major points for clinicians
solutions 134 – 135; considerations before 171 – 173; multicultural considerations
implementing DBT for 124 – 125; group in 25 – 26; other resources on 173 – 175;
session format 131 – 133; treatment in outpatient settings (see outpatient
targets in 126 – 128 settings); in partial hospital programs (see
confidentiality 34 – 35, 188 partial hospital program (PHP) settings);
connecting of present commitments to prior for post-traumatic stress disorder (PTSD)
commitments 23 152; in school sites (see school sites); for
consultation group 9, 74; in school sites 101 substance use disorders (see substance
contingency management 90 use disorders); team (see treatment
continuity of care 33 – 34 team); terminology 2, 3; as third wave
cope ahead skill 44, 92, 130 – 131, CBT 1; see also treatment
150 – 151, 200 dialectical dilemmas 16 – 17, 45 – 46, 202;
criminal justice system see conduct disorder, multicultural considerations 25
probation, and juvenile detention settings dialectical milieu 64 – 66
Crisis Stabilization Scale (CriSS) 93 – 94 dialectical strategies 10
dialectics 4 – 5, 45 – 46
daily goals 221 diary cards 41 – 42, 48 – 49, 178, 179, 180,
Daily Progress Report (DPR) 105 181; conduct disorder, probation, and
Daybreak Treatment Center 68 – 69, 68 – 73 juvenile detention settings 133 – 134;
DBT see Dialectical Behavior Therapy (DBT) family 58, 60; inpatient 93; life-
DBT-Linehan Board of Certification 78, threatening behaviors and 162; skills 183;
174 – 175 substance use disorders and 145
DEAR MAN 43, 195 different populations, implementation with
denial, adaptive 140 – 141, 233 21 – 22
depressed mind 155 Difficulties in Emotional Regulation Scale
depression 152 – 154 (DERS) 49
devil’s advocate, playing 22 – 23 Dimeff, L. A. 61, 81, 143
236
Index
directors of education in partial hospital foot in the door/door in the face 22

program settings 80 – 81 forcing autonomy vs. fostering
distress tolerance 7, 44 – 45, 57, 131 dependence 17
dodge 68 freedom to choose 23 – 24
doing what works 228 Frieburg Mindfulness Inventory (FMI) 82
do what works skill 129 Fruzzetti, A. E. 53 – 55, 57 – 58, 60
funding of inpatient care 94
eating, mindful 225
eating disorders: adaptations to treatment genograms, family 56, 208
targets for 112 – 114; additional treatment goals and problems, understanding 217
team members 112; biosocial model Goldstein, T. R. 154
and emotion dysregulation in 111 – 112; Grizenko, N. 64
challenges and solutions in treating 120; group orientation 206
considerations before implementing DBT group rules 207
for 109 – 111; group session format 117, groups: consultation 9, 74; problem-solving,
117 – 119; specific skills and adaptations in partial hospital program settings 71;
related to 115 – 117 skills 5 – 6
educational therapy and academic group session formats 46 – 47, 47 – 48;
preparation 70, 80 – 81 conduct disorder, probation, and juvenile
emotion, mindfulness of 156 detention settings 131 – 133; eating
emotional myths 197 disorders treatment 117, 117 – 119; family
emotional thesaurus 198 59; inpatient 92 – 93; substance use
emotional vulnerability vs. self-invalidation 17 disorders 143; Teen Talk 102, 103 – 104
emotion dysregulation, biosocial theory of Gunderson, J. G. 64, 65
3 – 4; conduct disorder and 125, 126;
eating disorders and 111 – 112 Harvey, P. 138, 143
emotion regulation 7, 43 – 44; in conduct health insurance issues 50 – 51
disorder, probation, and juvenile Health Insurance Portability and
detention settings 129 – 130; in Accountability Act (HIPAA) 34
relationships 58 Hoffman, P. D. 53, 55
emotions, understanding 196 homework, DBT 72, 214
excessive leniency vs. authoritarian control 17
implementation: for conduct disorder,
Family Adaptability and Cohesion Evaluation probation, and juvenile detention settings
Scale (FACES) IV 61 124 – 125; with different populations
family-based treatment for eating disorders 21 – 22; in different settings 21; for eating
110 disorders 109 – 111; in family counseling
family chain analysis 210 53 – 54; in inpatient settings 85 – 87; in
family counseling: adaptation to treatment outpatient settings 39 – 42; in partial
targets in 54; challenges and solutions hospital program (PHP) settings 64 – 68;
with 60; considerations for implementing in school sites 97 – 99; standard DBT vs.
DBT in 53 – 54; family skills group format DBT informed 19 – 20; structural/financial
in 59; outcome evaluation 60 – 61; in considerations in 21; for substance use
partial hospital program settings 80; skills disorders 137; training in 20; see also
adaptations in 54 – 59 treatment
family genograms 56, 208 individual sessions 8 – 9; in partial hospital
family therapy-interfering behaviors 15 – 16 program settings 80
food log 227 information sheet, DBT 189
237
Index
informed treatment, DBT 19 – 20 manic mind 155

initial diagnostic assessment 24 Matzner, F. J. 68
inpatient settings 85; adaptations to McCann, R. A. 125, 130
treatment targets in 88, 89; additional McMain, S. 139
treatment team members in 87 – 88; Medicaid 39
challenges and solutions 94 – 95; Medicare 39
considerations before implementing DBT Menghi, P. 72
in 85 – 87; group session format in 92 – 93; Miller, A. L. 1, 10, 11, 17, 71, 172; on
outcome evaluation 93 – 94; specific skills co-leading treatment 21; on do what
and adaptations for 89 – 92 works skill 129; on family crisis plans
interpersonal effectiveness 6 – 7, 43, 151; 57; on genograms 56; on mindfulness
myths 194 activities 42; on phone coaching for life-
Interpersonal Sensitivity (INT) 81 threatening behaviors 165; on treatment
intersession skills coaching 8, 116 – 117; targets in family counseling 54; Walking
conduct disorder, probation, and juvenile the Middle Path skills module 45
detention settings 131 mind, clear 230
Ivanoff, A. 130 mindfulness 6; conduct disorder, probation,
and juvenile detention settings and 129;
juvenile detention see conduct disorder, of current thoughts, in inpatient settings
probation, and juvenile detention settings 90 – 91; in eating 116, 225; of emotion
and bipolar disorder 156; exercises in
Kelly, E. 111 42, 193; of others for interpersonal
Kiddie-Sads-Present and Lifetime effectiveness 151; in partial hospital
Version 167 program settings 70; relational 56 – 57,
kindness: acts of 130, 229; loving 153 129; relationship 209; states of mind
and bipolar disorder 155; of worry
Latino clients 25 – 26 thoughts 150
leaders, team 31 miscommunication 35 – 36
life-threatening behaviors 14, 126, missing links analysis 212
161 – 166; with comorbid diagnoses 167 Monroe-DeVita, M. 61, 81, 143
Linehan, Marsha 1 – 2, 10, 11, 56, 65 – 66, multicultural considerations 25 – 26
71, 151, 172; on co-leading treatment
21; DEAR MAN acronym 43; on Narcotics Anonymous 141
dialectical dilemmas 16 – 17; on loving Native American clients 26
kindness 153; on mindfulness activities Nicholò-Corigliano, A. 72
42; on nurturance vs. benevolent no activity vs. over-activity 114
demandingness 66; on phone coaching nonjudgmental stance 125
for life-threatening behaviors 165; on normalizing pathological behaviors vs.
skills trainers 31; on stages of treatment pathologizing normative behaviors 17
13; on unwavering centeredness nurses 88
vs. compassionate flexibility 67; on nurturance vs. benevolent demandingness
willingness vs. willfulness 91 – 92 66 – 67
log, food 227 nutritionists 112
loving kindness 153
lunch time tasks 213 old school vs. new school 25
orientation and commitment strategies 10
making repairs 58 outcome evaluation 172 – 173; for additional
managers, case 32 diagnoses 156 – 157; conduct disorder,
238
Index
probation, and juvenile detention settings problem-solving strategies 11; in family

133 – 134; eating disorders treatment counseling 57; in partial hospital program
119 – 120; in family counseling 60 – 61; in settings 71
inpatient settings 93 – 94; in outpatient program coordinators in partial hospital
settings 48 – 49; in partial hospital program settings 81
program settings 81 – 82; in school pros and cons 23, 91
sites 102 – 105; substance use disorders provider communication form 190
treatment 143 – 146 psychiatrists 33, 80, 88
outcomes assessment 24 – 25 psychoeducation 56
outpatient settings: challenges and psychoeducational skills 5 – 6
solutions in 49 – 51; considerations before
implementing DBT in 39 – 42; diary cards quality-of-life interfering behaviors 16, 126;
in 41 – 42; group session formats 46 – 47, with comorbid diagnoses 168
47 – 48; outcome evaluation in 48 – 49;
standard skills modules for adolescents radical acceptance skill 44 – 45, 156, 201; in
in 42 – 46; traditional treatment targets in family counseling 57 – 58
40 – 41 Rathbone, B. H. 138, 143
outpatient therapists 87 – 88 Rathus, J. H. 1, 10, 11, 17, 71, 172;
over-protection vs. under-protection 25 on co-leading treatment 21; on do
what works skill 129; on mindfulness
panic attacks 150 – 151 activities 42; on phone coaching for life-
Papineau, D. 64 threatening behaviors 165
parental involvement and commitment rational vs. dynamic milieu models 68
to treatment for conduct disorder, rebellion, alternate 116, 140, 226
probation, and juvenile detention relational mindfulness 56 – 57, 129
settings 124 relationship mindfulness 209
parenting skills 58 – 59, 73, 141 residential staff and conduct disorder,
partial hospital program (PHP) settings probation, and juvenile detention
63 – 64; adaptations to DBT for 68 – 73, settings 128
73 – 74; behavioral expectations and rules Ricard, R. J. 104
of conduct in 219; considerations before Rizvi, S. L. 61, 81, 143
implementing DBT in 64 – 68; outcome
evaluation in 81 – 82; teen daily goal sheet school counselors 128
211; treatment adherence in 74 – 78; school sites 97; adaptations to DBT for
treatment team roles in 78 – 81 99 – 100, 101; challenges and solutions
phases of treatment 218; in partial hospital in 105 – 106; considerations before
program settings 75 – 77 implementing DBT in 97 – 99; consultation
phone coaching: for life-threatening team members and roles in 101;
behaviors 164 – 166; rules for 116 – 117 group session format in 102; program
physicians 32, 112 evaluation in 102 – 105; treatment targets
post-traumatic stress disorder (PTSD) 152 in 101, 102
pretreatment stage 12 – 13 secondary treatment targets, stage one
primary clinicians 31; in partial hospital 16 – 17; eating disorders and 112 – 113
program settings 80 self, validation of 151
private practice 39 self-injury 63, 161 – 166
probation see conduct disorder, probation, self soothing 91
and juvenile detention settings Shaller, Esme 76
probation officers 128 Silva, R. R. 68
239
Index
Silvan, M. 68 142 – 143; additional treatment team

skills adaptations: for anxiety 149 – 151; members and roles 141; challenges and
in conduct disorder, probation, and solutions 146; clear mind, clean mind,
juvenile detention settings 128 – 131; for and addict mind in 138; considerations
depression 152, 153; in eating disorders before implementing DBT for 137;
treatment 112 – 117; in family counseling group session format 143; key points
54 – 59; in inpatient settings 90; major to consider 146; outcome evaluation
points 171; in partial hospital program 143 – 146
(PHP) settings 68 – 73, 73 – 74; for post- suicide 63, 161 – 162
traumatic stress disorder (PTSD) 152; in Suicide Attempt Self-Injury Interview
school sites 99 – 100, 101; in substance (SASII) 162
use disorders 137 – 141 super groups 68
skills diary card 183 Swenson, C. R. 53, 55, 90
skills groups 5 – 6
skills modules in outpatient settings 42 – 46 target behaviors 192; stage one 14 – 16;
skills trainers 31; in partial hospital program traditional 40 – 41
settings 78 team see treatment team
Skills Training for Emotional Problem-Solving Teen Talk 100, 101; group session format
for Adolescents (DBT STEPS-A) 99 – 100 102, 103 – 104
smart phone applications 175 terminology, DBT 2, 3
Social Interaction Questionnaire (SIQ) 104 therapy-interfering behaviors 15 – 16;
staff turnover 50 by ancillary team members 35; with
stage four 14 comorbid diagnoses 168; in inpatient
stage one 13; secondary treatment targets settings 94 – 95; in partial hospital
16 – 17; treatment targets 14 – 16 program settings 78
stages, treatment 12 – 14; in partial hospital thinking errors 215
program settings 75 – 77 training 36, 172; implementation 20; in
stage three 13 – 14; eating disorders and school sites 99
110 – 111 treatment: adherence in partial hospital
stage two 13 program settings 74 – 78; ancillary modes
standard DBT 19 – 20; adaptation for 9; commitment 172; commitment to,
substance use disorders 137 – 141 in conduct disorder, probation, and
standard skills modules in outpatient settings juvenile detention settings 134 – 135;
42 – 46 with comorbid diagnoses 167 – 168;
State-Trait Anger Expression Inventory-2 consultation groups and 9; context
(STAXI-2) 134 in partial hospital program settings
STOP skill 45, 131 68 – 69; fidelity to 50; individual sessions
strategies, treatment 10 – 12 8 – 9; intersession skills coaching 8; life-
structural/financial considerations with threatening behaviors and 163; modes
implementation 21 of 5 – 7; stages of 12 – 14; strategies
structured eating plans vs. no eating plan at 10 – 12; 24-hour skills coaching 8; see also
all 114 implementation
stylistic strategies 11 – 12 treatment targets: conduct disorder,
Substance Abuse Subtle Screening Inventory- probation, and juvenile detention settings
Adolescent 145 – 146 126 – 128; in eating disorders treatment
substance use disorders 137; adaptations 112 – 114; in family counseling 54; in
from standard DBT for 137 – 141; inpatient settings 88, 89; in outpatient
additional treatment modes 141 – 142, settings 40 – 41; in school sites 101,
240
Index
102; stage one 14 – 16; in substance use validation 46, 204; in conduct disorder,
disorders 142, 142 – 143 probation, and juvenile detention settings
treatment team 21, 185; additional 125; in family counseling 57, 60 – 61; in
members in inpatient settings 87 – 88; partial hospital program settings 78; of
challenges and solutions 34 – 36; self 151
conduct disorder, probation, and juvenile validation strategies 11
detention settings 128; contacts 186;
continuity of care and 33 – 34; for eating Walking the Middle Path skills module 7, 45,
disorders 112; members and roles 29 – 33; 151, 203
role in school sites 101; roles in partial Ways of Coping Checklist (WCCL) 49
hospital program settings 78 – 81; for websites for DBT 174 – 175
substance use disorders 141; weekly medication management 187
turnover 50 willingness vs. willfulness 91 – 92, 220
Wisnewski, L. 111 – 113, 115
unrelenting crises vs. inhibited experiencing worry thoughts 150
17
unwavering centeredness vs. compassionate Youth Outcome Questionnaire (Y-OQ) 105,
flexibility 67 – 68 156 – 157
urge surfing 116, 139, 224
urine screens 143 Zeldow, P. B. 65
241

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Dialectical Behavior Therapy With

Dialectical Behavior Therapy With Adolescents is an essential, user-friendly guide

K. Michelle Hunnicutt Hollenbaugh, PhD, LPC-S, is an associate professor in the

Michael S. Lewis, PhD, LPCC-S, is a clinical professor at Capital University and

K. Michelle Hunnicutt Hollenbaugh

List of figures vii

1 Introduction and Overview 1

2 Treatment Delivery and Implementation 19

3 Treatment Team and Continuity of Care 29

6 Partial Hospital Programs and Settings 63

7 DBT in Inpatient Settings 85

8 Working Within School Sites 97

9 Eating Disorders 109

10 Conduct Disorder, Probation, and Juvenile Detention Settings 123

11 Substance Use Disorders 137

12 Other Diagnoses for Consideration 149

13 Comorbid Diagnoses and Life-Threatening Behaviors 161

14 Summary and Conclusions 171

1.1 Biosocial Theory 4

1.1 Definition of Terms in the Structure and Implementation of DBT 3

Shanice N. Armstrong, PhD is an assistant professor at Henderson State Univer-

K. Michelle Hunnicutt Hollenbaugh, PhD, LPC-S, is an associate professor in the

Mehmet A. Karaman, PhD is an assistant professor at the Department of Counsel-

Jacob M. Klein, M.Ed., is a Licensed Professional Clinical Counselor in the state of

Eunice Lerma, PhD is an assistant professor at the Department of Counseling and

Michael S. Lewis, PhD, LPCC-S, is a clinical professor at Capital University, and

research interests include college counseling, counselor development, and behavioral

Wannigar Ratanavivan, PhD, LPC, NCC is an adjunct graduate faculty member at

Dialectical Behavior Therapy (DBT) is considered a ‘third wave’ Cognitive Behavioral

WHY DBT IS DIFFERENT

to problem solve in order to make necessary changes. As a result, she developed

HOW TO USE THIS BOOK

Table 1.1 Definition of Terms in the Structure and Implementation of DBT

THE BIOSOCIAL THEORY OF EMOTION DYSREGULATION

Figure 1.1 Biosocial Theory

in the form of acronyms, and include aspects of problem-solving related to interper-

Walking the Middle Path

Table 1.2 DBT Dialectical Dilemmas

Common Dialectical Dilemmas Adolescent Specific Dialectical Dilemmas

Emotional Vulnerability vs. Self-Invalidation Excessive Leniency vs. Authoritarian Control

Intersession Skills Coaching

Orientation and Commitment Strategies

Validation and Problem-Solving Strategies

Case Management Strategies

STAGE ONE TREATMENT TARGETS

Decreasing Life-Threatening Behaviors

Decreasing Therapy-Interfering Behaviors

Behaviors That Interfere With Receiving Therapy

Behaviors That Interfere With Other Clients

Behaviors That Burnout the Clinician

Family Therapy-Interfering Behaviors

Clinician Interfering Behaviors

Decreasing Quality-of-Life-Interfering Behaviors

Increasing Behavioral Skills

STAGE ONE SECONDARY TREATMENT TARGETS—

Emotional Vulnerability vs. Self-Invalidation: The client will either experience

In addition to the behavioral patterns delineated by Linehan (1993), Miller et al.

Standard DBT vs. DBT Informed

Pros of Standard DBT Pros of DBT Informed

List of figures vii

1 Introduction and Overview 1

2 Treatment Delivery and Implementation 19

3 Treatment Team and Continuity of Care 29

6 Partial Hospital Programs and Settings 63

7 DBT in Inpatient Settings 85

8 Working Within School Sites 97

9 Eating Disorders 109

10 Conduct Disorder, Probation, and Juvenile Detention Settings 123

11 Substance Use Disorders 137

12 Other Diagnoses for Consideration 149

13 Comorbid Diagnoses and Life-Threatening Behaviors 161

14 Summary and Conclusions 171

1.1 Definition of Terms in the Structure and Implementation of DBT 3