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WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
1
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Dialectical Behavior Therapy with Multi-Problem Adolescents: Evolution
and Updates March 12, 2015
10-11:30am PST/1-2:30pm EST
Dialectical Behavior Therapy with Multi-Problem Adolescents: Evolution
and Updates March 12, 2015
10-11:30am PST/1-2:30pm EST
Jill H. Rathus, PhD
Professor of PsychologyLong Island University – CW Post Campus
Brookville, New York
AndCo-Director, Cognitive Behavioral Associates
Great Neck, NY
Jill H. Rathus, PhD
Professor of PsychologyLong Island University – CW Post Campus
Brookville, New York
AndCo-Director, Cognitive Behavioral Associates
Great Neck, NY
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Dialectical Behavior Therapy with Multi-Problem Adolescents: Evolution and Updates
Dialectical Behavior Therapy with Multi-Problem Adolescents: Evolution and Updates
• In the 1990s, Rathus and Miller began adapting DBT as the first comprehensive treatment for multi-problem adolescents at high risk for suicidal and self-injurious behavior.
• We developed DBT for adolescents (DBT-A) to address the complex and unique challenges that arise during treatment with multi-problem adolescents and their families.
• In the 1990s, Rathus and Miller began adapting DBT as the first comprehensive treatment for multi-problem adolescents at high risk for suicidal and self-injurious behavior.
• We developed DBT for adolescents (DBT-A) to address the complex and unique challenges that arise during treatment with multi-problem adolescents and their families.
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
2
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Dialectical Behavior Therapy with Multi-Problem Adolescents: Evolution and Updates
Dialectical Behavior Therapy with Multi-Problem Adolescents: Evolution and Updates
• This webinar:– Evolution of DBT-A.
• Overview of the adaptations made to standard DBT to address needs of adolescents and their families:
–Treatment modalities (including multi-family skills training group and family therapy sessions)
–Adolescent and family secondary treatment targets
–Latest DBT skills for adolescents/caregivers
• Suggestions for additional training and self-study in DBT-A
• This webinar:– Evolution of DBT-A.
• Overview of the adaptations made to standard DBT to address needs of adolescents and their families:
–Treatment modalities (including multi-family skills training group and family therapy sessions)
–Adolescent and family secondary treatment targets
–Latest DBT skills for adolescents/caregivers
• Suggestions for additional training and self-study in DBT-A
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Learning ObjectivesLearning Objectives
• Describe the evolution of DBT-A.
• Understand changes to treatment modalities in DBT-A and additions to DBT secondary treatment targets.
• Review recent updates to DBT skills for adolescents and their caregivers.
• Describe the evolution of DBT-A.
• Understand changes to treatment modalities in DBT-A and additions to DBT secondary treatment targets.
• Review recent updates to DBT skills for adolescents and their caregivers.
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
EVOLUTION OF DBT FOR ADOLESCENTS (WITH CHANGES IN MODALITIES AND TARGETS)
Dialectical Behavior Therapy with Multi-Problem Adolescents: Evolution and Updates
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Development of DBT for Adolescents
Development of DBT for Adolescents
• 1990s Montefiore Medical Center’s Adolescent Depression and Suicide Program, Bronx, NY
• Population: mostly suicide attempters, self-injurious behaviors, or SI, with multiple problems (school, family, substance abuse, trauma) & emotion dysregulation (many with BPD or features)
• 1990s Montefiore Medical Center’s Adolescent Depression and Suicide Program, Bronx, NY
• Population: mostly suicide attempters, self-injurious behaviors, or SI, with multiple problems (school, family, substance abuse, trauma) & emotion dysregulation (many with BPD or features)
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
4
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Limitations of Current Adolescent Research
Limitations of Current Adolescent Research
• At the time, no empirically validated treatments for these adolescents
• The related treatments focused on depression, excluded suicidal adolescents or those with multiple diagnoses, or were ER-based crisis interventions for suicide attempters
• At the time, no empirically validated treatments for these adolescents
• The related treatments focused on depression, excluded suicidal adolescents or those with multiple diagnoses, or were ER-based crisis interventions for suicide attempters
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Limitations of Current Adolescent Research
Limitations of Current Adolescent Research
• At the time, no empirically validated treatments for these adolescents
• The related treatments focused on depression, excluded suicidal adolescents or those with multiple diagnoses, or were ER-based crisis interventions for suicide attempters
• Alas!
• At the time, no empirically validated treatments for these adolescents
• The related treatments focused on depression, excluded suicidal adolescents or those with multiple diagnoses, or were ER-based crisis interventions for suicide attempters
• Alas!
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
DBT is designed for the severe and
chronic multi-diagnostic, difficult-to-treat patient
with both Axis I and Axis II disorders
DBT is designed for the severe and
chronic multi-diagnostic, difficult-to-treat patient
with both Axis I and Axis II disorders
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
DBT Research SupportRandomized Clinical Trials with Adults
DBT Research SupportRandomized Clinical Trials with Adults
• Linehan
• Koons
• Safer & Telch
• Craighead
• van- den Bosch & Verheul
• Lynch
• McMain
• Carter
• Turner
• Clarkin
• Feigenbaum
• Pistorello
• Van Dijk
• Linehan
• Koons
• Safer & Telch
• Craighead
• van- den Bosch & Verheul
• Lynch
• McMain
• Carter
• Turner
• Clarkin
• Feigenbaum
• Pistorello
• Van Dijk
16 RCTs at 13 independent sites
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Randomized Clinical TrialsRandomized Clinical Trials
DBT Superior to Comparison Treatments in Reducing:
–Suicide attempts and self injury–Premature drop out–Inpatient/ER admissions and days –Drug abuse
Depression, hopelessness, anger –Impulsiveness
And Increasing:–Global Adjustment –Social Adjustment
DBT Superior to Comparison Treatments in Reducing:
–Suicide attempts and self injury–Premature drop out–Inpatient/ER admissions and days –Drug abuse
Depression, hopelessness, anger –Impulsiveness
And Increasing:–Global Adjustment –Social Adjustment
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Treatment development: The problem
Treatment development: The problem
• In the 1990’s, we began piloting DBT within this inner-city outpatient clinic with teens and parents.
• Used original Linehan (1993) skills manual in its entirety – got participant feedback
• Many had difficulty reading the handouts and comprehending the material.
• Developmental needs were different
• Family context needed to be addressed; families needed to be engaged.
• In the 1990’s, we began piloting DBT within this inner-city outpatient clinic with teens and parents.
• Used original Linehan (1993) skills manual in its entirety – got participant feedback
• Many had difficulty reading the handouts and comprehending the material.
• Developmental needs were different
• Family context needed to be addressed; families needed to be engaged.
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
ModificationsModifications
We modified only where necessary, based on characteristics inherent to
adolescents
We thought,“we should use DBT, but we’ve got to make
it fit well for this population.”
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Montefiore & Long Island Univ.Montefiore & Long Island Univ.
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
8
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
DBT for Adolescents: ModificationsRathus & Miller, 2002, Miller, Rathus & Linehan, 2007
DBT for Adolescents: ModificationsRathus & Miller, 2002, Miller, Rathus & Linehan, 2007
• Skills training– Based on feedback from cohorts of families
• Modified language and look of original skills HOs• We at first shortened the length of treatment (12 – 16 weeks)
(also because of setting restraints)
– Teaching notes, examples, stories– Include families
• As-needed family interventions:– Family therapy sessions
• Using quasi-experimental design, published first adaptation (Rathus & Miller, 2002) which revealed promising results with suicidal teens
• Skills training– Based on feedback from cohorts of families
• Modified language and look of original skills HOs• We at first shortened the length of treatment (12 – 16 weeks)
(also because of setting restraints)
– Teaching notes, examples, stories– Include families
• As-needed family interventions:– Family therapy sessions
• Using quasi-experimental design, published first adaptation (Rathus & Miller, 2002) which revealed promising results with suicidal teens
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
DBT for Adolescents: ModificationsMiller, Rathus & Linehan, 2007; Rathus & Miller, 2015
DBT for Adolescents: ModificationsMiller, Rathus & Linehan, 2007; Rathus & Miller, 2015
• Skills training–Modified language and look of original skills
HOs
–Added Linehan’s new skills and expanded several
–Gradually re-introduced most material, expanding to six-month model (for 5 modules)
–Teaching notes, examples, stories
–Articulated our strategies for managing multi-family skills training
• Skills training–Modified language and look of original skills
HOs
–Added Linehan’s new skills and expanded several
–Gradually re-introduced most material, expanding to six-month model (for 5 modules)
–Teaching notes, examples, stories
–Articulated our strategies for managing multi-family skills training
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
9
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
DBT for Adolescents: ModificationsMiller, Rathus & Linehan, 2007; Rathus & Miller, 2015
DBT for Adolescents: ModificationsMiller, Rathus & Linehan, 2007; Rathus & Miller, 2015
Dilemmas and Problems:
Families getting polarized (repeating themes),
individual family members swinging from extremes,
not seeing one anothers’ perspectives,
and relying on inneffective means of trying to get their family members to change
Dilemmas and Problems:
Families getting polarized (repeating themes),
individual family members swinging from extremes,
not seeing one anothers’ perspectives,
and relying on inneffective means of trying to get their family members to change
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
DBT for Adolescents: ModificationsMiller, Rathus & Linehan, 2007; Rathus & Miller, 2015
DBT for Adolescents: ModificationsMiller, Rathus & Linehan, 2007; Rathus & Miller, 2015
– Skills training• Modified language and look of original skills HOs
• Added Linehan’s new skills and expanded several
• Gradually re-introduced most material, expanding to six-month model (for 5 modules)
• Teaching notes, examples, stories
• Family-based skills: Walking the Middle Path
–New Dialectical Dilemmas and Secondary Treatment Targets
–As-needed family interventions:• Family therapy sessions
• Parent training sessions
• Phone coaching for caregivers
– Skills training• Modified language and look of original skills HOs
• Added Linehan’s new skills and expanded several
• Gradually re-introduced most material, expanding to six-month model (for 5 modules)
• Teaching notes, examples, stories
• Family-based skills: Walking the Middle Path
–New Dialectical Dilemmas and Secondary Treatment Targets
–As-needed family interventions:• Family therapy sessions
• Parent training sessions
• Phone coaching for caregivers
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
What remains the sameWhat remains the same• Dialectical underpinnings• Biosocial theory of disorder• Functions
– Modes: Skills Training, Individual, Phone Coaching, Team
• Assumptions• Target hierarchy• Change procedures (exposure, cognitive
modification, contingency management, skills training)
• Treatment strategies (i.e., core, dialectical, stylistic, case management)
• Skills (retained virtually all original DBT skills)
• Dialectical underpinnings• Biosocial theory of disorder• Functions
– Modes: Skills Training, Individual, Phone Coaching, Team
• Assumptions• Target hierarchy• Change procedures (exposure, cognitive
modification, contingency management, skills training)
• Treatment strategies (i.e., core, dialectical, stylistic, case management)
• Skills (retained virtually all original DBT skills)
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
DBT Functions and ModesDBT Functions and ModesFunction Standard DBT Adolescent
Improve client motivation Outpatient Individual therapy
Outpatient Individual therapy
Enhance client capabilities Outpatient group skills training
Outpatient multi-family group skills training
Assure generalization to environment
Phone consultation Phone consultation (primary therapist coaches teens; skills trainers coach parents) (and including parents in skills training)
Structure the environment Case management: Family and organizational interventions
Case management: Sessions with family, parents, contact with school or other providers (agreed upon by teen and therapist)
Enhance therapist capabilities and motivation
Therapist consultation meeting
Therapist consultation meeting
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
11
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Adolescent ModesAdolescent Modes• Outpatient Individual Therapy • Multi-Family Skills Training Groups • Telephone Coaching for Teens and Family
Members • Family Sessions (as needed) • Parent Sessions (as needed)• Therapist Consultation Meeting • Graduate Group• Uncontrolled Ancillary Treatments
– Pharmacotherapy – Therapeutic/Residential Schools
• Acute inpatient hospitalizations
• Outpatient Individual Therapy • Multi-Family Skills Training Groups • Telephone Coaching for Teens and Family
Members • Family Sessions (as needed) • Parent Sessions (as needed)• Therapist Consultation Meeting • Graduate Group• Uncontrolled Ancillary Treatments
– Pharmacotherapy – Therapeutic/Residential Schools
• Acute inpatient hospitalizations
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Individual TherapyIndividual Therapy
• Strategies
• Diary Card review
• Targeting
• Behavioral Chain Analysis
• Solution Analysis
• Strategies
• Diary Card review
• Targeting
• Behavioral Chain Analysis
• Solution Analysis
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
12
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Stage 1 Primary targets Stage 1 Primary targets
Pre-Treatment ► Commitment & Agreement
• Decrease– Life-threatening behaviors
– Therapy-interfering behaviors
– Quality of life interfering behaviors
• Increase behavioral skills – Mindfulness
– Distress Tolerance
– Interpersonal Effectiveness
– Emotion Regulation
– Middle Path (adolescent-family adaptation)
Pre-Treatment ► Commitment & Agreement
• Decrease– Life-threatening behaviors
– Therapy-interfering behaviors
– Quality of life interfering behaviors
• Increase behavioral skills – Mindfulness
– Distress Tolerance
– Interpersonal Effectiveness
– Emotion Regulation
– Middle Path (adolescent-family adaptation)
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Targeting: Start with Diary Card to Organize Session Agenda
Primary targets - teens
Targeting: Start with Diary Card to Organize Session Agenda
Primary targets - teens
• Quality of Life Target emphases–School-related problems
–Peer-related problems
–Social media-related problems
–Family-related problems
• Diary card personalized
• Quality of Life Target emphases–School-related problems
–Peer-related problems
–Social media-related problems
–Family-related problems
• Diary card personalized
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
13
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
ModificationsModifications
The ProblemThe Problem
• Developmentally relevant, cognitive processing and capability differences
• Developmentally relevant, cognitive processing and capability differences
The SolutionThe Solution• We identified adolescent-
quality-of-life treatment targets (e.g., school-related, curfew, family conflict, peer-related, risk behaviors)
• Emphasized teen-appropriate examples, stories, exercises, and visually-engaging HOs.
• We identified adolescent-quality-of-life treatment targets (e.g., school-related, curfew, family conflict, peer-related, risk behaviors)
• Emphasized teen-appropriate examples, stories, exercises, and visually-engaging HOs.
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
14
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
ModificationsModifications
The ProblemThe Problem
• How to engage, teach, and treat the family.
• How to engage, teach, and treat the family.
The SolutionThe Solution
• We included families in treatment, identified adolescent-family secondary treatment targets, overall increasing use of environmental intervention.
• We included families in treatment, identified adolescent-family secondary treatment targets, overall increasing use of environmental intervention.
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
BiologicalSocialBiologicalSocial
EmotionalVulnerabilityEmotionalVulnerability
Active PassivityActive PassivityUnrelenting CrisesUnrelenting Crises
Self-InvalidationSelf-Invalidation
InhibitedExperiencingInhibitedExperiencing
Apparent CompetenceApparent Competence
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
15
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Dialectical Dilemmas: The task with adolescents
Dialectical Dilemmas: The task with adolescents
Distinguish true signs of –Emotional vulnerability
–Self-invalidation
–Active passivity
–Apparent competence
–Unrelenting crises
–Inhibited grieving
from what is expected for adolescent development
Distinguish true signs of –Emotional vulnerability
–Self-invalidation
–Active passivity
–Apparent competence
–Unrelenting crises
–Inhibited grieving
from what is expected for adolescent development
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Secondary Targets - TeensSecondary Targets - Teens
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
16
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Excessive Leniency(“too loose”)Excessive Leniency(“too loose”)
Forcing AutonomyForcing AutonomyNormalizing Pathological Behavior(“making lightOf problems”)
Normalizing Pathological Behavior(“making lightOf problems”)
Authoritarian Control (“too strict”)Authoritarian Control (“too strict”)
Pathologizing Normative Behavior (“making too muchOf normal teen behaviors”)
Pathologizing Normative Behavior (“making too muchOf normal teen behaviors”)
Fostering DependenceFostering Dependence
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Walking the Middle Path: How families can become polarizedWalking the Middle Path: How families can become polarized
Dialectical Dilemmas
Too loose --------------------------------------------------------Too strict
Making light of ------------------------------------Making too much of problem behaviors typical adolescent behavior
Holding on too ----------------------------------Forcing independence tight (doing everything) too soon (“you’re on
your own!”)
Dialectical Dilemmas
Too loose --------------------------------------------------------Too strict
Making light of ------------------------------------Making too much of problem behaviors typical adolescent behavior
Holding on too ----------------------------------Forcing independence tight (doing everything) too soon (“you’re on
your own!”)
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
17
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Dialectical Dilemmas: working toward synthesis
Dialectical Dilemmas: working toward synthesis
• Too loose vs Too strict : –INCREASE AUTHORITATIVE
PARENTING– Have clear rules and enforce them consistently.
Pay attention to your teen’s comings and goings, and friends.
• AND AT THE SAME TIME
–Be willing to negotiate on some issues• Be firm, yet flexible and fair
• Too loose vs Too strict : –INCREASE AUTHORITATIVE
PARENTING– Have clear rules and enforce them consistently.
Pay attention to your teen’s comings and goings, and friends.
• AND AT THE SAME TIME
–Be willing to negotiate on some issues• Be firm, yet flexible and fair
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Dialectical Dilemmas: working toward synthesis
Dialectical Dilemmas: working toward synthesis
• Making light of problem behaviors versus making too much of typical adolescent behavior –Recognize when a behavior “crosses the line”
and try to get help for that behavior
• AND AT THE SAME TIME
–Recognize which behaviors are part of typical adolescent development
• GIVE HAND-OUT: “What’s typical for adolescents and what’s not”
• Making light of problem behaviors versus making too much of typical adolescent behavior –Recognize when a behavior “crosses the line”
and try to get help for that behavior
• AND AT THE SAME TIME
–Recognize which behaviors are part of typical adolescent development
• GIVE HAND-OUT: “What’s typical for adolescents and what’s not”
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
18
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
What’s Typical for Adolescents, and What’s Not? (sample items)
What’s Typical for Adolescents, and What’s Not? (sample items)
Typical? Not Typical: Cause for Concern
Increased sexual maturation; increased focus on body image, self-consciousness
Sexual promiscuity; bingeing, purging, or restricting eating, social withdrawal
Sexual experimentation Multiple partners; unsafe sexual practices; pregnancy
Increased parent-teen conflict Verbal or physical aggression, running away, avoidance of all communication
Experimentation with drugs, alcohol, and cigarettes
Substance abuse, selling drugs, heavily substance-using peer group
Strong interest in technology; social media Spends many hours/day isolating on computer; on high-risk websites, casually meeting partners on line; revealing too much on-line
Stressful transitions to middle school or high school
Lack of connection to school or peers; school truancy, failure, or drop-out
Messy room Old, rotting food; teen not able to find basic necessities
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Dialectical Dilemmas: working toward synthesis
Dialectical Dilemmas: working toward synthesis
• Holding on too tight versus Forcing independence too soon–Give your adolescent coaching to help him/her
figure out how to be responsible & solve problems
• AND AT THE SAME TIME
–SLOWLY give your adolescent greater amounts of freedom and independence while continuing to allow an appropriate amount of reliance on others
• Holding on too tight versus Forcing independence too soon–Give your adolescent coaching to help him/her
figure out how to be responsible & solve problems
• AND AT THE SAME TIME
–SLOWLY give your adolescent greater amounts of freedom and independence while continuing to allow an appropriate amount of reliance on others
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Skills Training: Why Include Caregivers?
Skills Training: Why Include Caregivers?
And Why the new Middle Path Module?And Why the new Middle Path Module?
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
First, a word about DBT Treatment Settings with Teens…
First, a word about DBT Treatment Settings with Teens…
• Standard outpatient – with caregivers
• Inpatient
• Partial/Day hospital
• Residential–Inpatient – longer term
–Therapeutic boarding school
• Schools
• Forensic Settings
• Group homes
• Standard outpatient – with caregivers
• Inpatient
• Partial/Day hospital
• Residential–Inpatient – longer term
–Therapeutic boarding school
• Schools
• Forensic Settings
• Group homes
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
For settings where parents are not directly involved…
For settings where parents are not directly involved…
• Family meetings
• Orientation program
• Skills materials/readings/handouts/books
• Phone contact
• Referrals (e.g., Family Connections Program – Hoffman and Fruzzetti)
• Family meetings
• Orientation program
• Skills materials/readings/handouts/books
• Phone contact
• Referrals (e.g., Family Connections Program – Hoffman and Fruzzetti)
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Skills Training: Why Include Caregivers?
Skills Training: Why Include Caregivers?
And Why the new Middle Path Module?And Why the new Middle Path Module?
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
21
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Biosocial Theory of BPD (Linehan, 1993)Biosocial Theory of BPD (Linehan, 1993)
Jill Rathus, 2012 Do Not Use Materials Without Written Permission
Pervasive Emotion DysregulationPervasive Emotion Dysregulation
Biological Dysfunction in the Emotion Regulation SystemBiological Dysfunction in the Emotion Regulation System
Invalidating EnvironmentInvalidating Environment
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Why Include Family Members?Why Include Family Members?• Dialectical approach holistic, contextual• Skills acquisition for parents, since:
– May be dysregulated, overwhelmed– May not be interpersonally effective– May be inconsistent or extreme in parenting
• Intervenes directly: invalidating environment• Parents must be engaged to bring teens, follow through,
help teens solve problems • Models for more effective skill use?• Helps with skills generalization• Helps structure the environment: more reinforcing of
effective behaviors• Exposure for adolescents to parents as emotion-eliciting
stimulus• Increases parents’ social support
• Dialectical approach holistic, contextual• Skills acquisition for parents, since:
– May be dysregulated, overwhelmed– May not be interpersonally effective– May be inconsistent or extreme in parenting
• Intervenes directly: invalidating environment• Parents must be engaged to bring teens, follow through,
help teens solve problems • Models for more effective skill use?• Helps with skills generalization• Helps structure the environment: more reinforcing of
effective behaviors• Exposure for adolescents to parents as emotion-eliciting
stimulus• Increases parents’ social support
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Common Motives for Self-Harm in AdolescentsNock & Prinstein (2005, 2009)
Common Motives for Self-Harm in AdolescentsNock & Prinstein (2005, 2009)
• Intrapersonal–Negative reinforcement
• Reducing aversive arousal• Regulating emotions
–Positive reinforcement• Producing pleasant or desired sensations
• Interpersonal–Attains desired social outcomes
• Increases social support – peers• Increases parental support
• Intrapersonal–Negative reinforcement
• Reducing aversive arousal• Regulating emotions
–Positive reinforcement• Producing pleasant or desired sensations
• Interpersonal–Attains desired social outcomes
• Increases social support – peers• Increases parental support
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
How including caregivers in DBT can treat BPD features/emotion dysregulation
How including caregivers in DBT can treat BPD features/emotion dysregulation
• Treats context – targets familial antecedents &consequences of problem behaviors (e.g. suicidal behaviors, NSSI, impulsive behaviors, ineffective emotion displays)
• Biosocial Theory educates parents – re: emotional vulnerability – allows for effective responses (e.g., seeing suffering rather than “drama” or “manipulation”)– Different attitude + compassion + effective responses
= decreased emotional and behavioral escalations
• Treats context – targets familial antecedents &consequences of problem behaviors (e.g. suicidal behaviors, NSSI, impulsive behaviors, ineffective emotion displays)
• Biosocial Theory educates parents – re: emotional vulnerability – allows for effective responses (e.g., seeing suffering rather than “drama” or “manipulation”)– Different attitude + compassion + effective responses
= decreased emotional and behavioral escalations
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
How including caregivers through DBT skills training and family/parenting sessions can
treat BPD features/emotion dysregulation
How including caregivers through DBT skills training and family/parenting sessions can
treat BPD features/emotion dysregulation
• Increases caregiver validation & decreases invalidation–As such, can increase teen’s emotion
identification, emotion regulation, emotion expression, self-regulation and identity, and problem solving
• Increases interpersonal effectiveness & decreases interpersonal conflict and anger
• Increases effective contingency management/parenting strategies
• Increases caregiver validation & decreases invalidation–As such, can increase teen’s emotion
identification, emotion regulation, emotion expression, self-regulation and identity, and problem solving
• Increases interpersonal effectiveness & decreases interpersonal conflict and anger
• Increases effective contingency management/parenting strategies
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
How including caregivers in DBT can treat BPD features/emotion dysregulation
How including caregivers in DBT can treat BPD features/emotion dysregulation
• Treats parents–Parents acquire DBT skills
–Can reduce teen problems • social learning
• increased effective communication
• increased authoritative parenting (Baumrind: leads to increased self-regulation and best child outcomes)
• Treats parents–Parents acquire DBT skills
–Can reduce teen problems • social learning
• increased effective communication
• increased authoritative parenting (Baumrind: leads to increased self-regulation and best child outcomes)
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
RECENT UPDATES TO DBT SKILLS FOR ADOLESCENTS/CAREGIVERS
Dialectical Behavior Therapy with Multi-Problem Adolescents: Evolution and Updates
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Multi-Family Skills Training Group Format
DBT for Adolescents: Skills Updates
Core
MindfulnessDistress Tolerance
Emotion Regulation
Interpersonal
Effectiveness
Walking the Middle Path
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
25
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Family-Related Modifications in DBT for Adolescents
Rathus & Miller, 2015; Rathus & Miller, 2002; Miller, Rathus & Linehan, 2007
Family-Related Modifications in DBT for Adolescents
Rathus & Miller, 2015; Rathus & Miller, 2002; Miller, Rathus & Linehan, 2007
• Involve family members - skills training groups (multifamily format)
• Involve family members - skills training groups (multifamily format)
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Skills UpdatesSkills Updates
• Managing Group
• New skills–Expansion of Middle Path module
–Skills changes by module
• Managing Group
• New skills–Expansion of Middle Path module
–Skills changes by module
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Skills UpdatesSkills Updates
• Managing group –The challenges/needs brought up by including
parents• Many people in room
• Managing time, TIB, dysregulation, dialectical tensions
• Managing group –The challenges/needs brought up by including
parents• Many people in room
• Managing time, TIB, dysregulation, dialectical tensions
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Skills UpdatesSkills Updates
• Managing group –Using DBT strategies in group
• Acquisition, strengthening, and generalization
• Didactic, model, practice– Manage affect and engagement through activity choices that up-
regulate or down-regulate emotions
• Validation and change – shaping
• Warmth and irreverence; speed, movement & flow
• Dialectics “what a fabulous opportunity to practice your skills!”
• Engage members through teaching and theatre
• Managing group –Using DBT strategies in group
• Acquisition, strengthening, and generalization
• Didactic, model, practice– Manage affect and engagement through activity choices that up-
regulate or down-regulate emotions
• Validation and change – shaping
• Warmth and irreverence; speed, movement & flow
• Dialectics “what a fabulous opportunity to practice your skills!”
• Engage members through teaching and theatre
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Walking the Middle Path- Expanded
Rathus & Miller, 2015; Rathus & Miller, 2002; Miller, Rathus & Linehan, 2007
Walking the Middle Path- Expanded
Rathus & Miller, 2015; Rathus & Miller, 2002; Miller, Rathus & Linehan, 2007
–Dialectics & Dialectical Dilemmas
–Validation
–Behavior Change
–Dialectics & Dialectical Dilemmas
–Validation
–Behavior Change
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
MIDDLE PATH: DIALECTICSMIDDLE PATH: DIALECTICS
• Dialectics– What is it?
• Two things that seem like opposites can both be true
• More than one way to see a situation or solve a problem
– How to use it?• Move from “either-or” to “both-and”
• Examples:
– Working to accept your situation AND change it
– You’re doing the best you can AND you need to do better
– My mom is really strict AND she cares a lot• Practice looking at all sides of a situation; find the kernel of truth in every
side
– Your point of view makes sense AND my point of view makes sense
• Dialectics– What is it?
• Two things that seem like opposites can both be true
• More than one way to see a situation or solve a problem
– How to use it?• Move from “either-or” to “both-and”
• Examples:
– Working to accept your situation AND change it
– You’re doing the best you can AND you need to do better
– My mom is really strict AND she cares a lot• Practice looking at all sides of a situation; find the kernel of truth in every
side
– Your point of view makes sense AND my point of view makes sense
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Excessive Leniency(“too loose”)Excessive Leniency(“too loose”)
Forcing AutonomyForcing AutonomyNormalizing Pathological Behavior(“making lightOf problems”)
Normalizing Pathological Behavior(“making lightOf problems”)
Authoritarian Control (“too strict”)Authoritarian Control (“too strict”)
Pathologizing Normative Behavior (“making too muchOf normal teen behaviors”)
Pathologizing Normative Behavior (“making too muchOf normal teen behaviors”)
Fostering DependenceFostering Dependence
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Dialectical Dilemmas: working toward synthesis
Dialectical Dilemmas: working toward synthesis
• Psychoeducation: dilemmas
• Provide scenarios for each pole of dilemmas; ask participants to generate middle path solutions
• Rate themselves on the poles - Discuss goals for reaching a Middle Path
• Teach & discuss middle path solutions– Continue in family sessions
• Psychoeducation: dilemmas
• Provide scenarios for each pole of dilemmas; ask participants to generate middle path solutions
• Rate themselves on the poles - Discuss goals for reaching a Middle Path
• Teach & discuss middle path solutions– Continue in family sessions
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
MIDDLE PATH: THINKING MISTAKES
MIDDLE PATH: THINKING MISTAKES
Review “thinking mistakes” such as:
all-or-none thinking
labeling
“should” statements
mental filter
These push us toward extreme thinking
Review “thinking mistakes” such as:
all-or-none thinking
labeling
“should” statements
mental filter
These push us toward extreme thinking
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
The cycle of invalidationThe cycle of invalidation
(Fruzetti & Shenk, 2008 )(Fruzetti & Shenk, 2008 )
Emotional dysregulation
Difficulties with
accurate self-
expression
Invalidation
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
MIDDLE PATH: VALIDATIONMIDDLE PATH: VALIDATION
• Validation–Definition
–What can we validate
–Validating self and others
–Why should we validate?
–A “how-to” guide with six steps• Range from active listening/staying focused to
conveying you understand how the person feels/looking for how the thoughts, feelings, or actions make sense
–Validation role plays
• Validation–Definition
–What can we validate
–Validating self and others
–Why should we validate?
–A “how-to” guide with six steps• Range from active listening/staying focused to
conveying you understand how the person feels/looking for how the thoughts, feelings, or actions make sense
–Validation role plays
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
MIDDLE PATH: BEHAVIORISMMIDDLE PATH: BEHAVIORISM• Expanded with more examples & worksheets
• Behavior Change–Positive reinforcement
• Consider behaviors to change in self and other
• Positive tracking HW
• Shaping
–Extinction/planned ignoring – when and how
–Effective and judicious use of consequences• Develop menu of “wise mind” consequences
• Pitfalls of punishment
• Expanded with more examples & worksheets
• Behavior Change–Positive reinforcement
• Consider behaviors to change in self and other
• Positive tracking HW
• Shaping
–Extinction/planned ignoring – when and how
–Effective and judicious use of consequences• Develop menu of “wise mind” consequences
• Pitfalls of punishment
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Acceptability of Walking the Middle Path (Rathus, Miller, Campbell and Smith, in press,
Amer. J. of Psychotherapy)
Acceptability of Walking the Middle Path (Rathus, Miller, Campbell and Smith, in press,
Amer. J. of Psychotherapy)
• Results: High acceptability of module, to teens & parents.
• Middle Path skills ranked highly among DBT skills perceived most helpful.
• The Middle Path skill Validation was considered most beneficial skill (to parents and teens) among all DBT skills, with reinforcement close behind.
• Results: High acceptability of module, to teens & parents.
• Middle Path skills ranked highly among DBT skills perceived most helpful.
• The Middle Path skill Validation was considered most beneficial skill (to parents and teens) among all DBT skills, with reinforcement close behind.
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
New skills developments and adaptations
New skills developments and adaptations
• Interpersonal Effectiveness–THINK skill for perspective taking and
benign interpretations (Think about other’s view, Have
empathy, multiple Interpretations for other’s behavior, including at least one benign interpretation, Notice ways they’ve been trying/struggling, use Kindness)
–Multiple teen-friendly scenarios of DEAR MAN, GIVE, FAST, + using together
• Interpersonal Effectiveness–THINK skill for perspective taking and
benign interpretations (Think about other’s view, Have
empathy, multiple Interpretations for other’s behavior, including at least one benign interpretation, Notice ways they’ve been trying/struggling, use Kindness)
–Multiple teen-friendly scenarios of DEAR MAN, GIVE, FAST, + using together
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
New skills developments and adaptations
New skills developments and adaptations
• Emotion Regulation– Parent-teen shared pleasant activities (behavioral
activation + family cohesion)
– Expansion of PLEASE• Sleep hygiene
• Balanced eating
– Cope Ahead (from Linehan, 2015)
– Check the facts/Problem solving (from Linehan, 2015)
– Teen values and priorities when considering long-term goals (adapted from Linehan, 2015)
– Expanded list of emotions for opposite action (e.g., jealousy, love; Linehan, 2015)
• Emotion Regulation– Parent-teen shared pleasant activities (behavioral
activation + family cohesion)
– Expansion of PLEASE• Sleep hygiene
• Balanced eating
– Cope Ahead (from Linehan, 2015)
– Check the facts/Problem solving (from Linehan, 2015)
– Teen values and priorities when considering long-term goals (adapted from Linehan, 2015)
– Expanded list of emotions for opposite action (e.g., jealousy, love; Linehan, 2015)
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
New skills developments and adaptations
New skills developments and adaptations
• Distress Tolerance–TIP
–Distress Tolerance Kits – HW show & tell
–Mindfulness– Cheat Sheet
– Why bother?
• Distress Tolerance–TIP
–Distress Tolerance Kits – HW show & tell
–Mindfulness– Cheat Sheet
– Why bother?
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
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Feasibility/pilot studies of DBT for adolescents (Mehlum, 2012, ABCT)
Feasibility/pilot studies of DBT for adolescents (Mehlum, 2012, ABCT)
• DBT for suicidal / self-harming adolescent outpatients
– Rathus & Miller, 2002
– Woodberry et al, 2008
– James et al, 2008
– Cooney et al, 2010
– Fleischhaker et al, 2011
• DBT for suicidal adolescent inpatients.
– Katz et al, 2004• DBT for long-term adolescent inpatient care
– McDonell et al, 2010• DBT for adolescents with bipolar disorder
– Goldstein et al, 2007• DBT for adolescents with anorexia
– Salbach-Andrae et al, 2008
• DBT for suicidal / self-harming adolescent outpatients
– Rathus & Miller, 2002
– Woodberry et al, 2008
– James et al, 2008
– Cooney et al, 2010
– Fleischhaker et al, 2011
• DBT for suicidal adolescent inpatients.
– Katz et al, 2004• DBT for long-term adolescent inpatient care
– McDonell et al, 2010• DBT for adolescents with bipolar disorder
– Goldstein et al, 2007• DBT for adolescents with anorexia
– Salbach-Andrae et al, 2008
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
RCT Data! RCT Data!
• Mehlum and colleagues (2014; University of Oslo, Norway) compared 16 weeks DBT with Enhanced Usual Care with adolescents with repeated suicidal behavior and self-harm (JAACAP, 53 (10): 1082-1091)
• DBT associated with– Decreased frequency of self-harm episodes
– Reduced severity of suicidal ideation
– Reduced depression
• DBT successful at engaging and retaining patients (treatment retention good in both conditions)
• Mehlum and colleagues (2014; University of Oslo, Norway) compared 16 weeks DBT with Enhanced Usual Care with adolescents with repeated suicidal behavior and self-harm (JAACAP, 53 (10): 1082-1091)
• DBT associated with– Decreased frequency of self-harm episodes
– Reduced severity of suicidal ideation
– Reduced depression
• DBT successful at engaging and retaining patients (treatment retention good in both conditions)
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
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CARES StudyCARES Study
• Large-Scale, multi-site adolescent-family RCT –U Washington & UCLA
–Collaborative Adolescent Research on Emotions and Suicide (CARES) Linehan, Berk, Asarnow, McCauley (in progress)
–26 weeks of DBT compared to supportive psychotherapy
–Adolescents with suicidal behavior and self-harm
• Large-Scale, multi-site adolescent-family RCT –U Washington & UCLA
–Collaborative Adolescent Research on Emotions and Suicide (CARES) Linehan, Berk, Asarnow, McCauley (in progress)
–26 weeks of DBT compared to supportive psychotherapy
–Adolescents with suicidal behavior and self-harm
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
DBT for Adolescents: Evolution and UpdatesDBT for Adolescents:
Evolution and Updates
• A Coming of Age for Adolescent DBT • A Coming of Age for Adolescent DBT
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
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Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
ConclusionsConclusions
• DBT for Adolescents is standard DBT –Modifications for adolescent development
• DBT for Adolescents designed to involve families
• Large-scale RCTs complete and near completion
• DBT for Adolescents is standard DBT –Modifications for adolescent development
• DBT for Adolescents designed to involve families
• Large-scale RCTs complete and near completion
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
ConclusionsConclusions
• Research is needed to determine–Critical components
–Optimal length
–Does including Middle Path improve outcomes?
–Does including caregivers enhance outcomes, and in what formats?
• Research is needed to determine–Critical components
–Optimal length
–Does including Middle Path improve outcomes?
–Does including caregivers enhance outcomes, and in what formats?
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
36
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
ConclusionsConclusions
• Future Directions–DBT and DBT skills have been applied to
a broad range of populations, many of whom not suicidal
–DBT in Schools (Mazza, Mazza, Murphy, Miller, & Rathus, in press, Guilford) • Comprehensive DBT in schools
• Skills only in schools for general or indicated populations
• Future Directions–DBT and DBT skills have been applied to
a broad range of populations, many of whom not suicidal
–DBT in Schools (Mazza, Mazza, Murphy, Miller, & Rathus, in press, Guilford) • Comprehensive DBT in schools
• Skills only in schools for general or indicated populations
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
Training and Self-Study Opportunities
Training and Self-Study Opportunities
• Self-study of books/articles –Rathus & Miller (2015); Miller, Rathus, & Linehan
(2007), Rathus & Miller (2000, 2002); Mehlum et al (2014, JAACAP)
–Linehan (2015a; 2015b; 1993a; 1993b)
• Future webinars in this series may be of interest
• Watch the Btech training schedule for selection of training options this summer/fall
• Self-study of books/articles –Rathus & Miller (2015); Miller, Rathus, & Linehan
(2007), Rathus & Miller (2000, 2002); Mehlum et al (2014, JAACAP)
–Linehan (2015a; 2015b; 1993a; 1993b)
• Future webinars in this series may be of interest
• Watch the Btech training schedule for selection of training options this summer/fall
WEBINARDialectical Behavior Therapy with Multi‐Problem Adolescents:
Evolution and UpdatesMarch 12, 2015 | Jill Rathus, PhD
Copyrighted Materials | Used with Permission from Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhDFor educational use only. Do not copy or distribute without permission.
Linehan Institute | Behavioral Tech, LLC ▪ 4746 11th Avenue NE, Suite 102 ▪ Seattle, WA 98105 ▪ Ph. (206) 675-8588 ▪ Fax (206) 675 8590 ▪ www.behavioraltech.org
37
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
“Youth is a time of opportunityBut also a time of risk. The risk for us is that If we fail to support the rapidly growing population ofyoung people around the world,we will be left to pick up the pieces.”Robert Blum, MD, MPH, PhD, Johns Hopkins, 2007
Copyrighted MaterialsUsed with Permission of Marsha M. Linehan, PhD, ABPP & Jill Rathus, PhD
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