Principles of Behavioral Assessment and Management of “Life-Threatening Behavior” in Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) in its initial iteration was developed for the treatment of suicidal and self-injuring adults. As a result, the assessment and management of suicidal and nonsuicidal self-injurious (NSSI) behavior was and is central to the conduct of standard DBT. In this paper the authors describe the DBT approach to suicide risk assessment including discussion of both comprehensive and targeted suicide risk assessment and the associated documentation. In addition, it describes when and when not to conduct such assessment. Finally, this article describes management of both imminent and distant suicide risk and the application of DBT treatment strategies that can be applied in session.     

You Can Take a Horse to Water But You Can’t Make it Drink’: Exploring Children’s Engagement and Resistance in Family Therapy

Children’s engagement and disengagement, adherence and non-adherence, compliance and non-compliance in healthcare have important implications for services. In family therapy mere attendance to the appointments is no guarantee of engaging in the treatment process and as children are not the main initiators of attendance engaging them through the process can be a complex activity for professionals. Through a conversation analysis of naturally occurring family therapy sessions we explore the main discursive strategies that children employ in this context to passively and actively disengage from the therapeutic process and investigate how the therapists manage and attend to this. We note that children competently remove themselves from therapy through passive resistance, active disengagement, and by expressing their autonomy. Analysis reveals that siblings of the constructed ‘problem’ child are given greater liberty in involvement. We conclude by demonstrating how therapists manage the delicate endeavour of including all family members in the process and how engagement and re-engagement are essential for meeting goals and discuss broader implications for healthcare and other settings where children may disengage.     

“We Didn’t Know”: Silence and Silencing in Organizations

This article examines the dynamic processes within organizations that contribute to systemic silence and silencing and the “we didn’t know” defense, particularly for those groups in which secrecy replaces transparency to the detriment of the organization and its members. The events of the past more than 10 years within the American Psychological Association (APA) surrounding the role of psychologists in interrogation of detainees, including advising on and monitoring interrogations that have been construed as torture, will serve as a case example of the systemic forces that may contribute to leading an organization away from its principal mission. I explore how what was done was turned into its opposite. That is: “We are protecting psychologists by providing them with ethical guidelines in detention centers with detainees” became the explanatory rubric for a position that violated the association’s stated mission and exposed the organization and individual members to public shame. In addition, I explore how self-silencing becomes a way of adapting to a culture that censures dissent.     

“I Didn’t Know It Existed Before You Called”: Protestant Clergy Experience, Education and Perceptions Regarding Genetics

Despite the intrinsic role religious/spiritual (hereafter, R/S) beliefs have in patient clinical decision-making and crisis coping, there is little research exploring the relationship that exists between clergy (professionals who provide R/S counsel and guidance) and genetic counseling patients. This qualitative, exploratory study was designed to explore Protestant clergy (N?=?8) perceptions of and experience with genetics-related issues. Data analysis revealed that a wide range of R/S perceptions regarding genetics-related issues exist within Protestantism, Protestant clergy have a basic understanding of genetic testing and conditions, and while directive counseling is inherent to Protestant clergy counseling, there appears to exist two opposing styles: unbiased and biased. Based on this information, there are two main implications for genetic counseling clinical practice. First, R/S assessments need to be increasingly implemented into genetic counseling sessions, so that the psychosocial needs of patients with specific R/S beliefs can be identified and addressed. An increase in R/S assessments may be accomplished by increased exposure in genetic counselor training, continuing education opportunities, and by establishing relationships with board-certified, professional chaplains. Second, genetic counselors can influence the genetic education and experience of clergy by raising awareness within their own R/S assemblies. Doing so can also serve to further educate genetic counselors in the R/S beliefs of their own traditions, thus increasing sensitivity, empathy and the quality of care provided.     

Commentary on Koons et al.’s (2013) “Negotiating for Improved Reimbursement for Dialectical Behavior Therapy: A Successful Project”

This paper provides a commentary of Koons, O’Rourke, Carter, and Erhardt (this issue), which takes an inspiring first step in bridging research and clinical practice. We encourage the field to take the following from this paper: (a) evidence-based treatment (EBT) can work in real-world settings; (b) publishable research can be accomplished in a purely clinical environment; (c) some insurance companies are willing to pay more for EBTs; and (d) getting sufficient pay for more time-consuming work has potential to help patients. Koons et al. found the crucial synthesis for all clinicians: In a purely clinical setting, research demonstrated that people got better and the providers were paid more for their work.     

“I didn’t understand their system,and I didn’t know what to do”: Migrant Parents’ Experiences of Mandated Therapy for Their Children

In this phenomenological study, we explored the experiences of migrant parents whose children received mandated therapy in Southern California. Migrants are people who move to a host country either voluntarily as immigrants or involuntarily as refugees. Mandated therapy means that the school or court system required that their children receive services from a mental health provider. Parents often participated by having to take parenting classes and join in some sessions with their children; however, the children were the identified clients. We conducted eight, in-depth interviews with migrant parents. We employed Giorgi and Giorgi’s (Qualitative research in psychology: expanding perspectives in methodology and design. American Psychological Association, Washington, 2003; Qualitative psychology: a practical guide to research methods. Sage, London, 2008) phenomenological psychological research approach to analyze data. Analysis revealed four constituents, which are overarching themes related to the essential structure of the shared phenomenon: (a) migrant parents encountered discrimination and devaluation; (b) migrant parents experienced increased exposure to US culture and the mental health system, which accelerated acculturation; (c) the degree of cultural sensitivity exhibited by providers both positively and negatively influenced participants’ attitudes and perceptions toward mental health services; and (d) migrant parents used their mandated therapy experiences as opportunities to examine their family relationships and to learn new skills and concepts.     

“You Have to Sit and Explain it All,and Explain Yourself.” Mothers’ Experiences of Support Services for Their Offspring with a Rare Genetic Intellectual Disability Syndrome

The experiences of mothers of adult offspring with Angelman, Cornelia de Lange, or Cri du Chat syndrome have not been previously explored in research. The current study focuses on experiences with social and medical services and the impact the rareness of an adult offspring’s syndrome has on the experiences of mothers. Eight mothers of adults with Angelman, Cornelia de Lange, or Cri du Chat syndrome were interviewed. Thematic Content Analysis was used to interpret the interviews. Four themes emerged from the analysis: (i) The rarity of their offspring’s syndrome, (ii) Uneven medical and social care service provision, (iii) The inertia of social care services, and (iv) Mothers as advocates. Mothers felt that the rareness of their offspring’s syndrome did not affect experiences with social care services, but did affect access to medical services and some aspects of day-to-day living. Accessing appropriate social care services was reported to be a lengthy and complex process. These data may help inform care service providers about how best to support adults with rare genetic syndromes and their families.     

Dialogue and Dominance in Couple Therapy for Depression: Exploring Therapists’ Responses in Creating Collaborative Moments

Previous investigations have found specific communication patterns in couples dealing with depression, specifically when depression concurs with conjugal conflicts. The presence of these patterns can reflect couples’ difficulties in engaging in collaborative communication during their sessions, posing a real challenge for therapists. This exploratory study uses a dialogical approach to examine issues of dominance and type of dialogue in two couples who differed in terms of their levels of dyadic adjustment. The therapists’ reactions were explored in order to detect the kinds of responses that were most effective at engendering a collaborative attitude in therapy sessions. The method used to analyze the dialogue was Dialogical Investigations of Happenings of Change (DIHC). Results on dominance indicated that the degree of quantitative and semantic dominance displayed by a different member of the couple in each case was illustrative of their relational dynamics, while in both cases interactional dominance was exercised by the therapists. Results on dialogue revealed that dialogic dialogue might help to coconstruct new shared meanings of depression. The findings indicated that certain responses by therapists as part of the dialogue could be useful in bringing about a reduction in hostility between the members of a couple, provided that the responses are maintained over the course of the session. Some research and clinical implications that emerge from the results are discussed.     

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.     

‘You can’t buy love’: trivializing and the challenge for religious education

While there has been an increase in empirical research which explores the spirituality of children, few studies have explicitly named and described factors which may inhibit children’s expression of their spirituality. This paper, emanating from the author’s own research into children’s spirituality in Australian Catholic primary schools, presents and describes one such factor, which has been termed trivializing. An example of hermeneutic phenomenological writing—the text—in which trivializing was revealed is presented, followed by a reflection upon the text guided by van Manen’s lifeworld existentials (lived body, lived time, lived space, lived human relations). In the light of this reflection some initial implications for nurturing the spirituality of children within the primary religious education classroom are presented.     

“I Didn’t Expect to Learn as Much as I Did”: Rewards of Caregiving in Young Adulthood

While much attention is given to unpaid caregivers in midlife, there is a notable gap in the literature regarding young adults in family caregiving roles. Although two out of 5 family caregivers are between the ages of 18 and 40, we know relatively little about these younger relatives providing support to ill and disabled family members. Understanding the experiences of this under-researched population is critical to effective social service provision for this new wave of caregivers. In addition, the challenges associated with caregiving are well documented, yet examining the positive aspects of caregiving is necessary to provide a balanced picture of caregiving. The purpose of this qualitative study was to explore the gains experienced by family caregivers in young adulthood. In-depth telephone interviews were conducted with a diverse sample of 22 individuals who were (or had previously been) caregivers while in young adulthood. Analysis of the data resulted in identification of four themes concerning gains experienced by young adult caregivers: a strengthening of family relationships, character growth, personal satisfaction in the care provided, and material benefit. This study sheds some understanding on rewards experienced by a subgroup of family caregivers who has received little attention—young adult caregivers.     

“Was It Good for You?”: Reply to Commentaries

In many ways, psychoanalysis revolutionized attitudes about sexuality. Yet by undertheorizing female erotic passion and downplaying the role of the clitoris, psychoanalysis perpetuated a long historical tradition of denying essential aspects of women's sexual experience. Psychoanalysis has at times contributed to women perceiving their own bodily erotic excitement as frightening, dangerous, and out of control. In this reply to the commentaries, the authors continue to explore the ways in which women and women's experience, especially their embodied sexual experience, are so often rendered invisible.     

“Doc,There's Something I Have To Tell You”: Patient Disclosure to Their Psychotherapist of Unprosecuted Murder and Other Violence

The current investigation examines the incidence of clients telling their psychotherapists of committing violent crimes for which they have not been prosecuted. Thirteen percent of the psychologists surveyed indicated that on at least one occasion a client self-disclosed to them during a psychotherapy session that he/she had murdered someone, not including the killing of another person in the line of duty in the military or as a public peace officer. One third of the psychologists had clients self-disclose an unprosecuted incident of a sexual assault, and more than two thirds had clients self-disclose an unprosecuted incident of a physical assault during a psychotherapy session. Data are reported on psychotherapists' views of the impact of such disclosures on the psychotherapy relationship, adequacy of being informed regarding legal obligations after hearing such reports of violence, and adequacy of graduate preparation to deal with these clinical situations.     

“I want to pray and I don’t want to pray”: expressive individualism and prayer

This article reports on a study of the relationship between expressive individualism, an important characteristic of individualistic cultures, and different varieties of prayer. Four dimensions of expressive individualism (autonomy, setting oneself apart from others, personal development, and the expression of emotions) and four types of prayer (petitionary, religious, meditative, and psychological) were distinguished. Data were collected from participants in internet forums on Christian religiosity (N?=?158); they were asked to complete questionnaires about expressive individualism and prayer. The relationship between expressive individualism and prayer was found to be an ambivalent one, and one that is negatively dominated by autonomy. After eliminating the effect of autonomy, two patterns remain visible, both of them characterised by a positive connection to religiosity. Setting oneself apart from others is associated with petitionary and religious prayer; personal development with meditative and psychological prayer. The explanation of this concealed longing for religion is sought in the pressure resulting from expressive individualism as a way of life.     

Rhythmic entrainment: Why humans want to,fireflies can’t help it,pet birds try,and sea lions have to be bribed

Until recently, the literature on rhythmic ability took for granted that only humans are able to synchronize body movements to an external beat—to entrain. This assumption has been undercut by findings of beat-matching in various species of parrots and, more recently, in a sea lion, several species of primates, and possibly horses. This throws open the question of how widespread beat-matching ability is in the animal kingdom. Here we reassess the arguments and evidence for an absence of beat-matching in animals, and conclude that in fact no convincing case against beat-matching in animals has been made. Instead, such evidence as there is suggests that this capacity could be quite widespread. Furthermore, mutual entrainment of oscillations is a general principle of physical systems, both biological and nonbiological, suggesting that entrainment of motor systems by sensory systems may be a default rather than an oddity. The question then becomes, not why a few privileged species are able to beat-match, but why species do not always do so—why they vary in both spontaneous and learned beat-matching. We propose that when entrainment is not driven by fixed, mandatory connections between input and output (as in the case of, e.g., fireflies entraining to each others’ flashes), it depends on voluntary control over, and voluntary or learned coupling of, sensory and motor systems, which can paradoxically lead to apparent failures of entrainment. Among the factors that affect whether an animal will entrain are sufficient control over the motor behavior to be entrained, sufficient perceptual sophistication to extract the entraining beat from the overall sensory environment, and the current cognitive state of the animal, including attention and motivation. The extent of entrainment in the animal kingdom potentially has widespread implications, not only for understanding the roots of human dance, but also for understanding the neural and cognitive architectures of animals.