Question 1

Can you talk about managing confidentiality when working with teens and their parents, especially in the context of suicide ideation and self-harm?

Jill Rathus · Accepted Answer

Confidentiality is a tricky thing when working with adolescents. They are minors, and of course parents are worried and typically want to give and receive as much information as possible about their teen's treatment and risk. On the other hand, teens will not trust the relationship with the therapist and disclose as much if the therapist regularly reports to parents. 
We first validate parents' fear and concern and wanting to know about what is going on with their teens, especially with regard to SI, NSSI, or other high risk behaviors. We then highlight the dialectic: "of course you'd want to know about your teen's suicidal behaviors. At the same time, your teen needs to trust the therapist to accurately report on the diary card and discuss and get help with target behaviors, and would likely feel much more inhibited if the therapist continually reported these behaviors to you, the parent(s)." 
We then explain our approach, which is a synthesis of these positions: we will keep routine sorts of reports on behaviors confidential (such as stable/low levels of suicide-related behaviors such as ideation, urges, or minor self-injury, or other risk behaviors), should we not believe they are at risk of imminent harm to themselves, while continually monitoring, urging and trouble shooting coach calls before clients engage in risk behaviors, targeting, assessing, and relentlessly problem solving these behaviors with the client. In other words, we will keep close tabs on these behaviors with your teen and the last thing we would want is for the teen to withhold them from their therapist, or for them to escalate unchecked. On the other hand, should the behaviors indicate risk of imminent danger to oneself, such as suicide planning or intent, concerning levels of self-injury, placing oneself in life-threatening situations, or engaging in therapy-interfering behaviors such as skipping sessions while concerning target behaviors are present, we will break confidentiality and ensure these behaviors of concern get communicated to the parents. This could happen in a number of ways. Depending on the urgency, we might call the parents directly, call the teen and have the teen put the phone on speaker so we can have a conversation together, or call the parents in for a family session. We want to keep in mind the spirit of the DBT consultation to the patient agreement, and so even if we determine the parents must be informed about risk behaviors, we might consult with the patient of their preferred way of informing their parents, and when possible coach them to themselves tell their parents in the presence of the therapist. Thus, if there is imminent risk to the patient, or the therapist believes that it is their ethical or legal duty to inform the parents about certain behaviors (such as their minor child becoming a drug dealer, or sneaking out with the car and driving drunk), the therapist might first let the teen know that they believe they need to inform the parents and explain their decision, validate the teen's reaction, and collaborate with the teen about how to do this most effectively. It is helpful to coach the teen regarding communicating such behaviors and to help them cope ahead for the aftermath of this communication. This empowers the teen even while taking away confidentiality. Giving the teen some control over how this is done can even strengthen the therapy relationship.
We also tell parents that we will accept information from them about the teen's behaviors, so that often, information sharing will be a one-way street. They are welcome to tell us their concerns, and we will  inform the teen that we heard from the parent and what the parent communicated. This helps the therapist gain information about the teen's life, provide reassurance to the parents that their concerns will be noted and addressed, and be honest with the teen about having heard from their parents.
Finally, parents can be crucial partners in safety planning concerning their teens. By communicating risk to them in family sessions, calls, or other ways, they can help with identifying signs of escalating risk, closely monitor their teens, restrict lethal means, and get appropriate help when needed. Good communication and trust all around is crucial to maximize the extent to which parents can partner with DBT therapists in keeping their teens safe.

Question 2

What do you think about the diagnosis of borderline personality disorder in young people?

Alec Miller · Accepted Answer

For many years, the diagnosis of BPD was controversial and frankly frowned upon by many for several reasons, including stigma, lack of insurance reimbursement for personality disorder diagnosis, and questions about the validity and stability of this diagnosis in younger people, to name a few. This prompted Alec's colleagues and him to write the following article: Miller, AL, Muehlenkamp, JJ, & Jacobson, CM. (2008). Fact or fiction: Diagnosing borderline personality disorder in adolescents. Clinical Psychology Review, 28, 969-981. Since that time, many other clinicians and researchers have studied this with increasing support for the existence of this diagnosis in young people. We recommend a comprehensive text on this topic, edited by Sharp and Tackett (2014), BPD in Children and Adolescents. The risk of not making the diagnosis or at least BPD features where appropriate is that child and adolescent professionals will be forced to assign other diagnoses that may be less accurate and which may take the treatment into other directions that may be less therapeutic.

Question 3

Do you advocate using DBT-informed strategies within the context of other interventions e.g., motivational interviewing or CBT?

Jill Rathus · Accepted Answer

I think the answer to this question is itself dialectical. On the one hand, sure! It can be very helpful to introduce a relevant skill or two from DBT as it applies to a client if they are not receiving DBT. And not only might it be useful to include a few skills from DBT as they fit the case, but also some of the principles of DBT, such as a non-judgmental stance, a transactional worldview, DBT assumptions, dialectical responses, the team agreements, commitment strategies when asking for change, validation, and more. In fact, I'd bet most DBT therapists would say that once they've learned and become serious practitioners of DBT, it forever changes and informs their thinking about their cases, regardless of whether a client is in formal DBT. 
On the other hand, I have seen the inclusion of DBT strategies used in ways that might inadvertently mislead a client, be confusing, or even possibly cause harm. This is when a well-meaning therapist brings in a few DBT skills handouts or other concepts from DBT, in the context of not doing DBT therapy. The client might not be clear on what treatment it is that she has received, and might mistakenly believe "that was DBT," or "now I know what DBT is because I've had exposure to it." In these ways a client might simply be misinformed. A more concerning scenario would be if the client receives a few skills or ideas from DBT as part of a CBT or other treatment, and mistakenly believes, "I've had DBT and it was just common sense/was superficial - just a few skills/didn't help." Or worse, if a client takes a turn for the worse regarding emotions, behaviors, and suicidality, and feels hopeless about life and treatment, believing they've now had the "gold standard" treatment - DBT - and it didn't help or they got worse.
I think a dialectical synthesis here is to be clear to our clients on what is full-mode DBT (individual therapy, skills training, outside of session coaching, and consultation team), what is DBT skills only, how one might be defining a "DBT-informed treatment," and what is another mode of treatment altogether with a handful of ideas from DBT brought in. This could clearly be defined on a provider's website, in information cards or brochures, and in face to face conversations with a client about exactly what the therapist is offering and is trained to deliver. It is very important that consumers be educated and are aware of what interventions they are receiving, so they can make fully informed decisions going into a treatment and know what they received coming out of a treatment. It is also important in these communications to be clear on what treatments through what delivery modes for what client problems are supported by the data (see, for example, the shortly forthcoming: Rathus, Berk, Miller, & Halpert: DBT for Adolescents: A Review of the Research, In Jamie Bedics (Ed), Handbook of Dialectical Behavior Therapy, Elsevier, In Press).

Question 4

Are DBT skills being used for the treatment of ADHD in adolescents?

Jill Rathus · Accepted Answer

There is some research supporting DBT for the treatment of ADHD in adolescents/young adults. For example, Fleming et al (2014) published a pilot randomized controlled trial in the Journal of Attention Disorders on providing DBT skills training groups for college students with ADHD. They found that the treatment was acceptable and feasible, and that the 8-week DBT skills condition resulted in greater improvements in ADHD presentation and executive functioning skills compared to providing skills handouts only. 
Presumably, mechanisms behind these changes might particularly include the use of mindfulness skills, to help increase awareness of present-moment experience and to help focus and regulate attention, by noticing a wandering mind and repeatedly bring it back to an object of focus. In addition,  emotion regulation skills might help with factors such as improving sleep and eating habits, problems with which can exacerbate attentional problems; they also can help reduce emotional vulnerability, stay on task by building mastery, and reduce painful emotions that might highjack our attention. Distress tolerance skills might help manage crises without making them worse by procrastinating or avoiding tasks, or by radically accepting one's attentional challenges and adjusting schedule and work conditions to maximize our attentional capacity. Finally, even interpersonal effectiveness skills could be helpful with managing ADHD, such as by reducing interpersonal conflict that further interferes with focus, or by asking a teacher for extra help or accurately expressing one's experiences to parents about difficulty with tasks and desiring support.

Question 5

How do you think that sleep problems should be addressed with adolescents?

Alec Miller · Accepted Answer

Sleep problems among teens should be taken seriously. We now know sleep adversely affects teens moods and can exacerbate unipolar and bipolar episodes. Further, impaired sleep can affect attention and concentration, physical health problems, and even worsen suicidal ideation and behavior, and non-suicidal self-injury in some youth (See McGlinchy et al., 2016, in Suicide and Life-Threatening Behavior) Jill and I added a worksheet in our manual (Rathus & Miller 2015) to address this very problem for teens (and adults) who have difficulty with sleep hygiene. It's called Best ways to get REST: 12 Tips for Better Sleep (p. 353). These tips are all taken from tried and truth methods administered by sleep experts and they are reviewed in detail in skills group and reinforced and tailored in both individual and sometimes family sessions if necessary. One thing is for certain, is that too many teens have screens, and in particular, their phones in bed with them. Understandably this poses a tremendous problem for these youth. When possible, ideally when a child is first given a phone, we urge parents to consider requiring the phone remain out of the bedroom during sleeping hours. If serious efforts have been made and sleep is significantly impaired consulting with a sleep expert further (either CBT-i for insomnia, or possibly pharmacological interventions) may be indicated. Moreover, it should be considered whether the sleep problem is secondary to depression and anxiety and if so sleep may improve secondarily as those conditions improve. It's important though not to rely on this latter point if weeks or months are impacted by various sleep difficulties and to treat the sleep problem more directly.

Question 6

What advice do you have for working with parents who have persistent difficulty in validating their teen's experience and emotions?

Alec Miller · Accepted Answer

One of the first things that we try to do when working with parents in a DBT framework is to elicit their personal experiences and try to validate the valid. In other words, we need to convey that it makes perfect sense for many parents of emotionally and behaviorally dysregulated youth to feel frustrated and sad. Parents often feel ineffective despite their best efforts. There's no parental manual so many are learning as they go--and many of their approaches may be based on they themselves were parented which was not always experienced as validating. In addition, some parents exhibit high frustration and anger to their kids and yet that's often the secondary emotion. When you assess carefully, many parents' primary emotion is anxiety and fear. They are afraid of what will happen if their kids continue on this trajectory and if they don't find an effective treatment after having years of ineffective treatments. They are worried their kids will get into trouble at school or interpersonally and often that doesn’t show in that way. If parents experience validation by the DBT therapist, they will become better emotionally regulated themselves. Invite the parents to try to accurately express their own worries to their kids with less expression of their anger/frustration. Teens can receive parental worry better than parental anger. Once teens are less guarded in the face of parental frustration/anger, and more tuned in to their parents experience of anxiety, they're more likely to accurately express their own emotions of sadness, frustration, shame--which parents can then try to validate with the proper skills coaching and training. We recommend parents and teens learn validation skills and practice on less "hot topics" before addressing the bigger issues with one another.

Question 7

What group rules have you added for online teen DBT groups?

Alec Miller · Accepted Answer

While online, we ask our families in multi-family group to sit together, with teen and parent/s side by side in one video view (zoom room), as opposed to having teen in one room and parents in the other. This improves teens behavioral compliance as well as parents who are hopefully modeling positive behaviors. Also ask families to leave themselves UNmuted unless a dog is barking so as to enhance spontaneity as we might have if we were altogether in the same room. When folks are muted, there's an increased passivity, it takes longer for people to respond, etc. We've asked members to show themselves in the video screen and not drift off out of sight.

Question 8

How do you use behavior chain analysis with teens?

Jill Rathus · Accepted Answer

We use behavior chain analysis with teens the same way we would with an adult client. We first orient to the procedure and provide a rationale, and get commitment (e.g., a devil's advocate strategy such as: "why would you want to be in a treatment that follows a hierarchy of targets, and then addresses a target behavior in this structured way, rather than in a therapy that lets you discuss whatever you feel like discussing, however you'd like to discuss it?"  Our teens will usually argue for it by saying something like, "well in my last therapy we just talked about whatever was on my mind and nothing really changed. It sounds like this will help me understand my problems better and figure out to solve them.") 
We then review the diary card at the beginning of sessions, and identify what to target according to the hierarchy as well as some collaboration (e.g., if there are 2 equally highly-rated quality of life behaviors, we might ask the adolescent which one seems more important to address in session, or look together at the associated emotion ratings and skills use and decide together). 
We then begin the chain analysis, getting a behaviorally specific description of the target behavior, assessing for the prompting event, determining vulnerability factors, assessing all relevant links on the chain, and assessing consequences of the target behavior. We either weave solutions in along the way, or once we complete the chain, depending on the flow of the conversation and what seems most effective. Some teens are more visual learners and benefit from the chain links being written out on a big pad of paper or a white board as we go through the chain, others might like to record the conversation to replay for themselves later, if this helps with their continued understanding of a situation that provoked strong emotions and ineffective behaviors. Some therapists have even made the chains more game-like for younger teens or kids, such as with each link written on separate colorful cards, or cutting strips of paper, writing down each link, and affixing the strips of paper together, making an actual chain of paper.
We even sometimes do a family chain analysis in a family therapy session. We tend to do this when family members' actions show up as important links on the adolescent's chain, or when there has been a crisis in which a caregiver is involved. We will thus invite the caregivers into session with the teen, and conduct the chain, simultaneously assessing links from both parties' perspectives - that is, what were each party's problem behaviors, prompting events, vulnerability factors, key antecedents, and key responses (i.e., consequences) to the problem behaviors identified. We can then collaboratively weave in productive solutions having understood multiple perspectives. These solutions will not only often include mindfulness, distress tolerance, and emotion regulation skills, but will often include middle path skills such as dialectical thinking, and interpersonal effectiveness skills such as being gentle, acting interested, using validation, and speaking in an easy rather than a harsh manner. Family chain solutions will also include other DBT change strategies such as exposure to avoided emotions, challenging faulty cognitions, and new contingency management strategies.

Question 9

What are the most effective ways to get teens to complete and bring diary cards to therapy?

Alec Miller · Accepted Answer

There are several important methods to consider in helping increase diary card compliance. First, it is important that commitment to DBT treatment is obtained. Further, that the teen has endorsed at least 3 out of 5 problem areas (e.g., impulsivity, emotion dysregulation) to ensure this treatment modality makes sense. Next, itt's helpful to make the teen connect the dots. Just because the teen has 3-5 problem areas and thus needs DBT skills to address them doesn’t mean it makes sense to him or her. Can you help the teen identify his or intermediate/long-term goals and HOW do these problem areas interfere in achieving those goals. For example, how does one's self-injury or angry outbursts affect the goal of having better peer and family relationships. How does unremitting depression and inactivity impact the goal of increasing extra-curricular clubs and improving resume to be competitive for college. Once those dots are "connected" it's an easier sell to join the skills group to learn these critical life skills. To help teens learn and practice these skills, the therapist introduces the diary card to help the teen track the use and effectiveness of these skills. The point here is it's critical to get heavy duty commitment with rationale, etc, before asking them to bring it home and return it completed each week. Furthermore, I tell them once committed, this is the first thing I ask for when they enter my office next week and if they forget it, they need to complete a blank one and we will then conduct a behavioral chain analysis of what got in the way.... Another consideration is if the client hasn’t started skills group yet it may be worth suggesting the teen only complete the top of the diary card (emotions and target behaviors) and not worry about the bottom half of the card yet. One more suggestion is having them practice completing ONE day (yesterday) of the card in front of you the therapist in the office so you can answer questions and have them experience filling it out (it takes only a minute or two each day). Finally, trouble shooting is critical. WHERE do they keep the card each day, WHEN do they fill it out, HOW will they remember to bring it back for next Tuesday's session.

Question 10

I see the benefits to running your multi-family DBT group with parents and teens in the same group, but curious if you ever recommend running the two separately? This recently came up in a team discussion to manage our group offerings as we focus on virtual care.

Jill Rathus · Accepted Answer

We don't typically recommend running DBT skills groups separately for teens and caregivers, although we recognize that some settings might choose that format for various reasons or might not have access to caregivers to include them. Over the many years we have adapted, implemented, and studied this treatment, we have come to endorse the multi-family model because of its many benefits. It is also the only model supported by the data in 2 large-scale randomized controlled trials (Mehlum et al., 2014; McCauley et al, 2018). (Although, the "horserace" study comparing these two approaches in an RCT has not yet been conducted.) 
When parents and teens are in the same group learning skills side by side, they can learn and discuss the biosocial theory together, learn a common language of skillful behavior, see their family member completing homework and working hard to apply the skills, view their family member's struggles and perseverance firsthand, experience behavioral rehearsal of key skills directly with their family member, view the modeling by other families of skillful interactions, practice experiencing strong emotions in the presence of their family member while remaining present and skillful, and witness other families reporting on meaningful progress and graduating skills group together. They also later report that the special time together in group (focused on just that teen and not on other siblings) additionally strengthens their relationship. While many teens may protest the multi-family group format at first, they typically feel comforted by seeing their parents become more skillful and be held accountable to an equal degree for learning and practicing the skills. So with regard to efficient family skills acquisition, to skills generalization, to structuring the environment to be more supportive, and even to provide hope and inspiration, we do recommend the multifamily format with parents and teens together whenever possible.

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