Dialectical Behavior Therapy Applied to Parent Skills Training: Adjunctive Treatment for Parents With Difficulties in Affect Regulation

Poor outcomes in parent training programs have been associated with parental psychopathology in general, and difficulties in parental affect regulation in particular. Although many parents may be able to learn behavioral management skills in a controlled therapy setting, for those who experience affect dysregulation, generalization of these skills to the natural environment may be challenging when their emotions are aroused. Parents, particularly those who struggle with affect dysregulation around their child's behavior, may benefit from dialectical behavior therapy (DBT) because it specifically targets problems in emotion regulation. Thus, the purpose of this article is to discuss relevant aspects of DBT (e.g., dialectics, biosocial model, and validation) and highlight its applicability to parents who struggle with affect dysregulation. Several clinical case studies will also be presented to elucidate how mental health professionals can address the affect dysregulation in parents by teaching them DBT skills to manage their own negative emotions, particularly when their child's behavior is the source of emotional arousal.     

How do counsellors make client assessments?

This paper reports on a consultation exercise undertaken with 18 experienced counsellors on how they make client assessments. These practitioners expressed a high degree of consensus on the purposes of assessment making (to reach a shared understanding with the client about their willingness and ability to undertake a shared therapeutic journey) but the way in which they approached the task varied according to the theoretical orientation they acquired during training. Although most had developed their counselling skills and techniques considerably since initial training, not all had integrated the assessment implications of later experience into their formulation making. The implications of combining single model assessment with eclectic practice are discussed, particularly in relation to making a decision to continue working with a client or to refer a client to a colleague. The authors call for further debate on how counsellors find meaning in what their clients say, why they ask the questions they do at the assessment stage, and how they achieve coherence in relation to ideas and skills accrued through ongoing training and practice. The implications of such a debate for training and supervision are discussed.     

Skills Practice in Dialectical Behavior Therapy for Suicidal Women Meeting Criteria for Borderline Personality Disorder

Dialectical Behavior Therapy (DBT) is an evidence-based practice for borderline personality disorder (BPD) and suicidal behavior that has been replicated with a variety of populations. Patients’ practice of behavioral skills taught in the group skills training component of DBT may be partly responsible for the positive treatment outcomes according to the skills deficit model of BPD that underlies DBT. This study was designed to examine the type and frequency of skills practiced by DBT patients. Participants were 49 women, who met criteria for BPD and current and chronic suicidal behavior, receiving 1 year of standard DBT as part of a clinical trial. Skills were recorded on the daily diary cards completed by participants each week and reviewed by their individual therapists. Results indicated that the majority of participants reported practicing skills most days throughout treatment. Crisis survival and mindfulness skills were practiced most frequently in our sample. Hierarchical linear modeling demonstrated that skills practice increased as a function of time in therapy. Directions for future research are discussed.     

Bilingual Therapeutics: Integrating the Complementary Perspectives and Practices of Motivational Interviewing and Dialectical Behavior Therapy

Informed by the practice of code-switching or style-switching in linguistics, “bilingual therapeutics” is proposed as the complementary integration of two evidence-based practices in psychotherapy: motivational interviewing (MI) and dialectical behavior therapy (DBT). Unique features of MI and DBT are presented, current research of each practice is reviewed, and their similarities and distinctions are discussed. It is proposed that fluency in both “languages” of MI and DBT may usher in a new therapeutic perspective to enhance client case conceptualization, illuminate subtleties of the therapeutic process, and foster more intentional and deliberate practitioners. Specifically, MI and DBT code-switching may help recruit and retain clients in formal treatment (e.g.,”speaking” MI more prominently to prepare clients for 12-month standard DBT) and promote consultation among therapists. The complementary integration of MI and DBT also suggests the emergence of a linguistic “third space,” including “spirit as synthesis” and “improvisational dance.”     

Understanding the social emotional practices of therapists

Emotions are central to the therapy process and skilful use by therapists of client emotion is an essential catalyst to client change. However, the contribution of emotion to the therapy process and how therapists’ social emotional skills are incorporated into psychological practice is still unclear. Using a statistical method for mapping psychological constructs, therapists’ social emotional skills were transformed into a “map” with three spatial dimensions, which was supported by comparative reliability checks. The nature of social emotional skills was further investigated by administering a Q-Sort of emotional practice items to 47 therapists. Ten highly applicable clusters of social emotional skills across seven style patterns with therapists were identified. Tentative links were drawn between demographic data and both clusters and therapist styles. These findings suggest therapists’ social emotional skills can be organised into meaningful clusters and that therapists can be styled according to their responses across these clusters. Furthermore, gaps identified in the model suggest possible “blind spots” in the literature. The implications of these findings are significant for training and practice.     

Therapists’ perspectives about working with meaning in life in psychotherapy: A survey

Of 212 practicing therapists who completed a survey about working with meaning in life (MIL) in psychotherapy, 129 (61%) had recently worked with MIL with at least one client and reported on their work with a client in this survey. Those therapists who had worked with a client on MIL as compared with those who had not were older, more experienced, more humanistic/existential/experiential in orientation; reported more MIL training; and felt more competent working with MIL. Clients reported on primarily had internalizing, interpersonal, and career issues. Only 12% of clients explicitly labeled MIL as an issue coming into therapy. The three most frequently used interventions involved offering support; helping clients examine thoughts, feelings, and behaviors to discover hopes and goals; and facilitating exploration of MIL cognitions and experiences. Therapists reported many positive consequences from working with MIL. Therapists reported minimal training in MIL and moderate competence in working with MIL. Implications for practice, training, and research are presented.     

Negotiating for Improved Reimbursement for Dialectical Behavior Therapy: A Successful Project

Dialectical Behavior Therapy (DBT) is an evidence-based treatment for borderline personality disorder that has been widely disseminated to many outpatient treatment settings. Many practitioners depend on third-party payers to fund treatment delivery. DBT requires additional clinical services not often included in outpatient therapy, including a weekly skills group led by 2 clinicians, and the requirement for clinicians to attend weekly consultation team and provide intersession contact for coaching. Standard outpatient insurance rates for individual and group sessions do not provide adequate reimbursement for the additional services of DBT. This paper describes how 2 DBT team leaders collaborated to obtain improved reimbursement for their programs. The 2 teams met with insurers, educated them about DBT, and showed outcomes from their programs to achieve large increases in reimbursement rates. The paper includes client outcome data from both programs.     

A Sequential Analysis of Clinician Skills and Client Change Statements in a Brief Motivational Intervention for Young Adult Heavy Drinking

This study examined sequential relationships between clinician skills and client statements about behavior change in a randomized clinical trial comparing a brief motivational intervention (BMI) to a relaxation training control condition (REL) in a sample of heavy drinking young adults. Clinician and client interactions (N = 167) were assessed according to two established observational rating systems. Sequential analyses examined the transitional associations between clinicians’ use of MI-eliciting skills (i.e., questions and reflections), MI-supportive skills (e.g., affirmations, emphasize client autonomy, statements of support), MI-inconsistent skills (e.g., confrontations, unsolicited advice), and subsequent client statements about behavior change (i.e., change talk or sustain talk). In both conditions, clinicians’ use of MI-elicitation skills operated in a manner that was largely consistent (100% in BMI; 84% in REL) with the directional relationships proposed by MI theory (i.e., The Technical Hypothesis). More detailed analyses of the BMI condition showed clinician skills were related to statements about behavior change somewhat differently in drinking compared to coping discussions. While elicitations of change talk were associated with increased odds of their intended response (i.e., distal drinking and proximal coping change talk), elicitations of proximal coping sustain talk were associated with higher odds of proximal change talk. MI-supportive skills were also associated with increased odds of proximal change talk, and instances of proximal sustain talk were rare in the sample. This fine-grained analysis presents sequential transitions to client change and sustain talk with greater classification specificity than has been previously reported. Such efforts have the potential to advance our understanding of the function of MI skills in promoting client discussions about drinking (i.e., evoking) and coping (i.e., planning) behavior change.     

How Do Experienced Family Therapists View Their Practice? An Exploratory Assessment of Clinical Skills and Their Relation to Theories of Family Therapy

This study examines the fit between theory based therapeutic skills and the perceptions of experienced therapists about their own skills. Participants responded to a measure of family therapy skills. Of the generic skills, two factors were identified which cut across many areas of practice. For the theory specific skills, two factors were identified which cut across four theories of family therapy. One was consistent with an expert style of therapy and the other reflected a collaborative approach to practice. These findings suggest that clinical training in family therapy should develop ways to train clinicians to match their clinical practice with client needs over theory based models.     

The facilitative interpersonal skills method: Difficult psychotherapy moments and appropriate therapist responsiveness

The Facilitative Interpersonal Skills (FIS) task is a performance test of therapists’ use of common relational skills (e.g. empathy, building expectations). The FIS method includes (a) materials that simulate difficult client moments on video, which are used to collect therapists’ responses to these situations; and (b) independent ratings of these responses. Many of the FIS items are informed by psychotherapy processes that have been linked to outcome and facilitative conditions that have been reframed as individual therapist skills (e.g. alliance bond capacity). Overall, the FIS has predicted psychotherapy outcome. A single study is described in which FIS predicted the therapist effect using multilevel modelling of a large sample of clients who were nested within therapists. We also summarise two additional outcome studies that used experimental designs. One future direction is to better understand how therapists form responses to these difficult moments. We conclude that forming an optimal therapeutic response during challenging, emergent in‐session situations involves responsiveness (Stiles et al., 1998), or finding a response that fits the clients’ needs within any moment.     

Initial relationship goal and couple therapy outcomes at post and six-month follow-up

The purpose of this study was to investigate the relationship between client initial goal for couple therapy (i.e., improve the relationship or clarify the viability of the relationship) and the outcomes (including their relationship status, i.e., separated or together) at posttreatment as well as at 6-month follow-up. Two hundred forty-nine couples (N = 498 individuals) seeking treatment for relationship distress in a naturalistic setting were treated by 20 therapists. Client initial relationship goal was attained by intake paperwork protocol, which included client initial goal for couple therapy and client perception of partner goal. Clients who reported that their goal was to improve the relationship reported better outcomes at post. Couples who reported their goal was to improve the relationship were less likely to break up at a 6-month follow-up. Of the 115 couples stating they wanted to improve the relationship, only nine (7.8%) couples were separated at 6 months. In contrast, of the 16 couples in which both partners wanted to clarify the relationship prior to therapy, nine (56%) were separated at follow-up. Therapist awareness of each individual's relationship goal prior to couple therapy could enhance outcomes, and treatment tailored according to initial goals could set the stage for positive outcomes however defined.     

Theoretical Purity Versus Theoretical Layering in Marriage and Family Therapy

There seem to be two competing streams of thought about the use of theory in the marriage and family therapy literature: theoretical purity versus integrationism. We examined influence of theoretical orientation on client experience in therapy. Level of academic training (masters' versus doctoral degree) was investigated as a possible confounding variable. Results suggest that therapists in private practice are less inclined to practice pure forms of therapy.     

A Functional Approach to the Assessment and Treatment of Non-Suicidal Self-Injury in Veterans: A Dialectical Behavior Therapy–Informed Perspective

Given that non-suicidal self-injury (NSSI) is related to increased odds of suicidal ideation and suicide attempts, treating NSSI in veterans is a key treatment priority to help reduce suicide risk and increase quality of life. Treating NSSI can be difficult for clinicians and training in addressing NSSI can enhance therapist empathy and decrease negative attitudes. The current paper describes prevalence of and risk factors for NSSI in veterans and presents a Dialectical Behavior Therapy (DBT)-informed approach for arriving at a functional understanding of NSSI in order to inform assessment and treatment. This DBT-informed approach is demonstrated with two case examples of veteran clients. While in many circumstances treatment of NSSI may be most effective in the context of full model DBT (i.e., individual therapy, group skills training, phone coaching, and therapist consultation team), many aspects of the functional approach discussed herein are not specific to DBT and could therefore be integrated into behavioral analyses and case formulations conducted within non-DBT therapeutic approaches.     

The analysis of verbal interactions occurring during consultation

This article describes a consultation analysis technique for coding conversion between a consultant (e.g., psychologist) and a consultee (e.g., teacher) serving a client (e.g., student). Consultation analysis classifies the topics discussed in consultation, the verbal processes exhibited during consultation, and the extent to which one participant in consultation controls the kinds of things which another participant says. Uses of consultation analysis in training and research are discussed.     

A Dialectical Behavior Therapy Skills Group Case Study on Mothers With Severe Emotion Dysregulation

Parenting is an emotionally demanding endeavor, which can be particularly challenging for parents who struggle with psychopathology and lack the regulation skills to manage their own emotional lability. Although dialectical behavior therapy (DBT) is an effective treatment that directly targets emotion dysregulation, little is known about whether DBT might also improve parenting behaviors. A DBT skills group was employed to examine whether DBT skills are utilized by mothers in their parenting and whether skill use improves parenting. Four mothers with severe emotion dysregulation who met diagnostic criteria for at least one Axis I disorder were part of a case study, in which they completed a DBT skills group for mothers, and two of the mothers participated in an in-depth exit interview regarding their use of DBT skills in their parenting. The mothers reported substantial changes in their parenting during the exit interview and modest improvements were found for parenting in pre- to posttreatment parenting assessments. This paper describes the various parenting contexts in which DBT skills were used and discusses maternal emotion regulation as a potential pathway from DBT skills to improved parenting.     

Erotic Countertransference and Clinical Social Work Practice: A National Survey of Psychotherapists' Sexual Feelings,Attitudes, and Responses

Male and female social work psychotherapists were surveyed on sexual feelings toward clients, sexual behavior with clients, and utilization of erotic countertransference. Relationships between these variables and therapists' self-reports of training in erotic counter-transference, utilization of supervisory consultation, length of clinical experience, and theoretical orientation were also examined. Male therapists were significantly more likely than females to report sexual attraction toward clients, and to report using erotic countertransference to further treatment goals. The frequency of therapists' discussion of sexual feelings toward clients in supervision was related to the reported frequency of utilization of sexual feelings in treatment. The majority of therapists reported that their social work training did not prepare them adequately to work with erotic countertransference.     

Well,That Was Awkward: When Clients Develop Romantic Feelings for Therapists

Clients can develop feelings of romantic or sexual attraction to their therapists. From a cognitive-behavioral perspective, how should therapists handle these situations? Although the topic of client attraction is comprehensively covered in the psychoanalytic and psychodynamic literature, it is woefully neglected in our cognitive-behavioral therapy (CBT) focused training programs and literature. This paper aims to address this gap by using CBT principles to provide explanations for why clients develop feelings of attraction to their therapists. In addition, this paper offers general guidelines for how to manage client attraction from a CBT perspective. Three case vignettes are used to illustrate those concepts. Recommendations for future research and training in this area are also provided.     

Novice therapist,the client and therapy: Integrating the triad

Therapy process research focuses on understanding how therapy is conducted by professionals in the field. It is a nascent field of psychotherapy enquiry in India. This paper explores how novice therapists in India perceive their clients, and how this influences the process of therapy. In depth interviews were conducted with ten novice therapists, with less than six years of practice experience, from Mumbai, India. The data was thematically analysed. The data revealed that therapists' perceptions of their clients were defined by socio-demographic features of age and gender, along with presenting complaints and personal attributes. Participants had defined beliefs about good clients as contrasted with difficult ones. Distinct preferences for particular client types were identified. The antecedents to these beliefs were attributed to the therapist's worldview, their training and the supervision received. These views, and the conceptualisation of the client, influenced the choice of client, the process of therapy and how they proceeded with sessions, and their methods of referral. The data from the study has implications for therapist training, supervision and further research.     

A Both-And Approach: An Application of Narrative Interventions from a Modern Perspective

A contentious debate between the modern and postmodern epistemologies continue to wage on since the rise of constructivism and social constructionism in the 1990s. This debate has led to both modern and postmodernists falling into an either/or mindset. Others have proposed a solution, the both-and approach, that emphasizes integration of different therapeutic camps. Intentionality is a core component of this approach, as therapists must understand how employed interventions flow from the epistemology and theoretical orientation under which they operate. Another core component of this approach is tailoring the integration to the specific context of the client case. With this understanding and tailoring, therapists can utilize methods across the modern/postmodern divide, as they will coherently flow from their original epistemology and theoretical orientation. Applying methods from both modernism and postmodernism, then, enhances therapists’ therapeutic repertoire, allowing for more opportunities to adapt treatment to each client case. Altogether, the quality of services improve and the amount of clients therapists can help increases as well. This paper will provide an application of the both-and approach to a case study to provide an example of how the said method can be employed in therapy.