As discussed in Chapters 2 and 3, DBT considers suicidal and other behaviors associated with BPD as products of emotion dysregulation. The behavioral patterns resulting from this dysregulation are characterized by vacillations between polarized positions. Each pattern represents transactions between an emotionally vulnerable individual and his or her invalidating environment. Over time, the individual with BPD learns to alternate between behavioral extremes that either underregulate or overregulate emotion; in this sense, such behavior patterns can be understood as dialectical failures (Linehan, 1993a). DBT views these patterns of shifting between behavioral extremes as “dialectical dilemmas” for the client, in that the client alternately tries, but is unable to make work, each extreme approach to emotion regulation. The first three primary treatment targets discussed in Chapter 3 (life-threatening behaviors, therapy-interfering behaviors, and quality-of-life-interfering behaviors) are themselves expressions of these dialectical dilemmas. Because these behaviors endanger the client’s life or the therapy itself, or impair the quality of the client’s life, they must be immediately addressed and so take precedence. But the overall patterns help sustain the dysfunctional behaviors, and so the patterns themselves need to be targeted by treatment if there is to be long-term change. Therefore, DBT has a set of secondary treatment targets. These treatment targets involve finding syntheses of the client’s extreme behavioral styles. The therapist attends to these secondary targets throughout treatment, weaving them into behavioral analysis, insight strategies, and discussion of other issues as relevant.
The standard DBT dialectical dilemmas are as follows:
Emotional vulnerability versus self-invalidation
Active passivity versus apparent competence
Unrelenting crises versus inhibited grieving
The three additional adolescent-specific dialectical dilemmas we have developed (Rathus Miller, 2000) are these:
Excessive leniency versus authoritarian control
Normalizing pathological behaviors versus pathologizing normative behaviors
Forcing autonomy versus fostering dependence
At each polar extreme, there are two secondary treatment targets: one aimed at decreasing the maladaptive behavior, the other aimed at increasing a more adaptive response. Table 5.1 lists the dialectical dilemmas and corresponding secondary treatment targets in standard DBT, and Table 5.2 lists those developed for an adolescent population. Note that while these behavior patterns are helpful in conceptualizing clients’ behavior, they are not universal; thus, for a given case, they should be assessed rather than assumed (Linehan, 1993a). In the following sections, we discuss each dialectical dilemma as it tends to present in adolescent clients, and then also discuss its corresponding treatment targets.
DBT regards “emotional vulnerability” as a core feature of BPD; the term as used here refers to the experience of intense emotional suffering. At this pole, emotional vulnerability is the experiential side of emotion dysregulation (see Chapter 3 on biosocial theory). Individuals with emotional vulnerability are often highly emotionally aroused, which creates not only behavioral instability but also dyscontrol over cognitions, physiological arousal, facial expressions, body language, and communications. Moreover, emotional vulnerability is accompanied by the phenomenological experience of being out of control, which stems from a lack of influence over emotionally evocative stimuli, combined with the inability to modulate reactions to these stimuli.
Four characteristics accompany the frequent, intense, and tenacious emotional arousal of clients with BPD (Linehan, 1993a). The first is that emotions are not unidimensional physiological events, but rather full-system responses involving also cognitive, experiential, and expressive/behavioral responses. Thus such clients must attempt to regulate this entire system of responses associated with emotional states (e.g., internal arousal, facial expression, action patterns)—a formidable task. Second, this intense emotional arousal disrupts even behaviors that are usually planned, regulated, and functional, causing the client to become demoralized and making negative emotions even worse. Third, the inability to regulate the high emotional arousal gives the client a frightening sense of the uncontrollability and unpredictability of emotional reactions. Fourth, this lack of control leads to fears of both situations over which the client has little control and expectations of valued others. Thus new situations, challenging situations, and even praise from a therapist (which can be accompanied implicitly by expectations of maintaining or furthering progress) can be terrifyingly daunting, further maintaining the vulnerability.
TABLE 5.1. Standard DBT Dialectical Dilemmas, with Corresponding Secondary Treatment Targets
| Dilemma | Targets |
| Emotional vulnerability versus self-invalidation | Increasing emotion modulation; decreasing emotional reactivity |
| Increasing self-validation; decreasing self-invalidation | |
| Active passivity versus apparent competence | Increasing active problem solving; decreasing active passivity |
| Increasing accurate communication of emotions and competence; decreasing mood dependency of behavior | |
| Unrelenting crises versus inhibited grieving | Increasing realistic decision making and judgment; decreasing crisis-generating behaviors |
| Increasing emotional experiencing; decreasing inhibited grieving | |
TABLE 5.2. Adolescent Dialectical Dilemmas, with Corresponding Secondary Treatment Targets
| Dilemma | Targets |
| Excessive leniency versus authoritarian control | Increasing authoritative discipline; decreasing excessive leniency |
| Increasing adolescent self-determination; decreasing authoritarian control | |
| Normalizing pathological behaviors versus pathologizing normative behaviors | Increasing recognition of normative behaviors; decreasing pathologizing of normative behaviors |
| Increasing identification of pathological behaviors; decreasing normalization of pathological behaviors | |
| Forcing autonomy versus fostering dependence | Increasing individuation; decreasing excessive dependence |
| Increasing effective reliance on others; decreasing excessive autonomy | |
The suffering that accompanies the inability to regulate emotion can create despair that one is doomed to a life of unending misery. In fact, one can make the analogy that clients with BPD or borderline features are the “psychological equivalent of third-degree burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering” (Linehan, 1993a, p. 69). At one extreme, these clients can sink into such despair that suicide appears the only way out. At the other, the clients can become so angry that suicide to punish others appears reasonable, because others either do not understand their pain or cannot help them. Thus extreme statements such as “I’ve suffered through all this—it’s amazing I haven’t killed myself yet,” or “I’ll die and I’ll show you!” may appear dramatic, and yet may reflect clients’ attempts to convey their actual overwhelmed, hopeless experience.
Emotional vulnerability may be harder to discern in adolescent clients than in others. Compared to younger children or adults, adolescents report more negative moods, greater extremes of mood, and more mood lability (Buchanan, Eccles, & Becker, 1992; Csikszentmihalyi & Larson, 1984; Larson & Richards, 1994). This increase in moodiness has been attributed primarily to cognitive and environmental factors (Larson & Richards, 1994), rather than to the biological changes of puberty. For example, adolescents not only experience an increase in negative life events and personal transitions; they also have the abstract reasoning capacity to consider the far-reaching implications of these events (Arnett, 1999; Larson & Ham, 1993; Larson & Richards, 1994). In fact, changes in emotional development include the increase in frequency of a range of psychological conditions, including mood disorders, conduct disorders, eating disorders, and suicide attempts (Brooks-Gunn & Petersen, 1991; Garner, 1993; Rutter, 1986; U.S. Department of Justice, 1994; U.S. Department of Health and Human Services, 1994). Conflicts with parents increase, and tensions commonly arise (Galambos & Almeida, 1992). Furthermore, adolescents’ increased sense of the uniqueness of their experiences, and increased self-consciousness due to a feeling of being “on stage” (Berk, 2004; Lapsley, 1991), often result in their being perceived as “melodramatic.” Moreover, adolescents today face unique sets of stressors, including increased drug and alcohol use (Substance Abuse and Mental Health Services Administration, 1996), violent crimes (as either victims or perpetrators; CDC, 1992), and gang membership.
Despite these characteristics of adolescence, Arnett (1999) has suggested a modified “storm and stress” view of this period. He asserts that although there is indeed an increase in moodiness, argumentativeness, and stressors in adolescence compared with other stages of the life span, emotional instability is not inevitable, and many teens in fact adjust well. Thus, while many youth encountering such stressors will suffer a deteriorating course, many will grow up to be successful adults. A key task of therapists, then, involves distinguishing true signs of emotional vulnerability from the expected vicissitudes of adolescence. Signs that emotional variability is going beyond normative adolescent moodiness and dramatic presentation include intransient states of depressed or otherwise negative moods; continuous extreme sensitivity and emotional arousal, with marked difficulty returning to baseline mood; identification of diagnosable conditions (e.g., major depression, substance abuse, conduct disorder); and evidence of severely maladaptive coping with moodiness or stressors (e.g., self-harm behavior, drug use, school problems, association with a delinquent peer group, or social withdrawal).
“Self-invalidation” refers to taking on characteristics of the emotionally invalidating environment (see Linehan, 1993a). These include invalidating one’s own emotional experiences, and thus trying to suppress the experience or expression of emotions; distrusting one’s own perceptions, thus undermining identity and looking to others to define one’s reality; responding to one’s own emotional states with negative secondary emotions such as shame, disgust, or anger; and oversimplifying the ease of problem solving, expressed by denying one’s problems or blaming oneself for them (e.g., “I’m overreacting,” “I should be able to do more,” etc.). At this end of the polarity, clients may want to commit suicide to punish themselves, believing that they deserve to die. Alternatively, suicide can be an outcome of unrealized perfectionism associated with invalidation of one’s true difficulties in achieving goals.
This behavior may be especially difficult to identify and change in adolescents at the beginning of treatment. It is typical for children not to trust themselves, and to engage in “social referencing”—that is, looking to parents and other authority figures for cues as to how to react, interpret situations, and feel (Berk, 2004). In this sense, self-invalidation is rather normative, particularly in younger adolescents. Yet adolescence is a time when increasing separation from parents occurs, and a greater sense of trusting oneself develops. Certainly by later adolescence (i.e., ages 16–18), greater trust in oneself and stronger self-validation should be apparent.
In regard to targeting self-invalidation in treatment, adolescent clients present several challenges. First, adolescent clients are typically residing within their original invalidating environment, which serves as a powerful model for self-invalidation. Second, adolescents are increasingly susceptible to influence by peers. When peers are invalidating (e.g., “That’s ridiculous!”, “You are such a loser!”), adolescents are likely to internalize such messages. Third, adolescence is the primary period for identity development. According to Erikson (1968), the major psychological conflict of adolescence is identity versus identity diffusion. Those with trouble formulating an identity (identity diffusion) have a poor sense of themselves, their values, and their goals. Related to identity formation is the notion of self-concept. In adolescence, the self-concept evolves to include an expanded definition of self, including insight into one’s psychological qualities (Barenboim, 1977), personal values and aspirations, and the need to be liked by others (Berk, 2004). Thus weakly established identities and self-concepts may make teens more likely to question their perceptions and look to others to define themselves—hallmarks of self-invalidation.
For minority youth or recent immigrant youth, the development of an identity comes with even more challenges than for youth from the mainstream culture. Teens from ethnic minority backgrounds face the task of reconciling the values of their own ethnic culture with those of the dominant culture (Phinney & Rosenthal, 1992). Too strong an identity with their own minority group may limit their opportunities in the dominant culture, while allying too strongly with the dominant culture may lead to being ostracized by their own group (Phinney & Rosenthal, 1992). Discrimination, lack of successful role models, and reduced SES are further conditions faced by many minority adolescents as they struggle to form an identity (O’Conner, 1989; Spencer, Dornbusch, & Mont-Reynaud, 1990) and may further intensify self-invalidation.
On a more hopeful note, the development of formal operational thinking provides adolescents with the capacity to make choices about their world views, their personal values, and their future occupations. Adolescents become able to imagine various options and roles without having actually experienced them (Kahlbaugh & Haviland, 1991). Self-concept during adolescence becomes based on an expanded range of areas, including romantic relationships, peer acceptance, and academic and job success (Harter, 1990). Thus there is the potential to integrate new information and change the pattern of self-invalidation.
To summarize this first dialectical dilemma, it involves vacillating between self-blame (e.g., “I was so stupid to react that way!”, “I’m the cause of all my troubles”) and blaming or attacking others (“How could he do that to me and make me this upset?”, “I’m a helpless victim”), and between oversimplifying life’s problems and feeling so overwhelmed by life that suicide seems the only option. The extremes of self-invalidation mean that teens consider themselves inadequate, shameful, responsible for their difficulties, and even deserving to die. On the other hand, teens’ accentuation of emotional vulnerability means blaming their troubles on everyone or everything other than themselves. Self-blame is consistent with the adolescent tendency toward egocentrism (Lapsley, 1991). At the same time, externalizing blame is common to adolescents as they increase their argumentativeness and criticism (Elkind, 1984).
In dealing with this pattern, the therapist must also be dialectical. He or she has to avoid colluding with the self-invalidation that can occur with badly timed or too strong an emphasis on change and problem solving. On the other hand, the therapist has to avoid colluding with emotional vulnerability by badly timed or too strong a stance of acceptance and validation. The therapist’s task is to find a balance between acceptance and change. As the therapist’s stance shifts, so too do the secondary behavioral treatment targets aimed at increasing and decreasing specific behavior. See Table 5.3 for an overview of this dialectical dilemma, its corresponding treatment targets, and related strategies and techniques.
The treatment targets of increasing emotion modulation and decreasing emotional reactivity are both aimed at the emotional vulnerability pole of the dialectical dilemma. Together they involve “turning down the volume” on the intense, dysregulated emotional states characteristic of emotional vulnerability. The goal is not completely inhibiting emotions, but helping teens to moderate the extremity of their emotional responses. A therapist teaches a client emotion regulation skills to modulate emotional responses, such as observing and describing emotions (mindfulness skills are required here as well), reducing emotional vulnerability through self-care and building a sense of mastery, and acting opposite to the current emotion.
TABLE 5.3. Targeting Emotional Vulnerability versus Self-Invalidation
In targeting self-invalidation, the therapist works to overcome the influence of the invalidating environment. The teen needs to learn to validate his or her emotions, perceptions, and approach to problem solving, in place of extreme emotional displays to elicit such validation from one’s environment. The therapist employs strategies to (1) enhance the adolescent’s self-trust through attending to emotional cues and rational thoughts; (2) encourage nonjudgmental observation and labeling of emotional states, rather than inhibition of them; (3) expose the teen to primary emotions that are unrealistic for the situation and that cause negative secondary emotions; (4) invoke the emotion regulation skill of opposite action to activate self-validating behaviors (i.e., the therapist stops a self-invalidating statement and has the client replace it with a self-validating statement); and (5) promote the teen’s use of shaping (i.e., rewarding him- or herself for small increments of progress toward goals.
“Active passivity” describes a coping style characterized by approaching difficulties with passivity and helplessness, while actively eliciting the help of others in solving problems. This coping style stems in large part from the inability of individuals with BPD or borderline/suicidal features to prevent the experience of extreme aversive emotions, coupled with a sense of helplessness in resolving their own problems. At this point, they become especially vulnerable to the threat of loss of relationships and may frantically attempt to prevent abandonment. Because of a helpless yet demanding style, individuals manifesting active passivity are likely to alienate caregivers and ultimately experience rejection or invalidation.
Active passivity in an adolescent is in some ways strikingly different from expected behavior. This is because most teens strive for increased individuation from parents, spend more time with peers, and experiment with their new decision-making and planning capacities (Elkind, 1984; La Greca & Prinstein, 1999; Larson & Richards, 1991). Teens typically want to drive a car or use public transportation themselves, begin to earn their own money, and handle personal problems with less intrusion from parents (e.g., Lapsley, 1991).
On the other hand, other aspects of adolescent development may exacerbate a state of active passivity. First, teens may realistically be more dependent upon others to solve their problems, if they are indeed dependents living at home. That is, they may need others for things like money or transportation. Second, in the areas in which they can help themselves, they may be overwhelmed by their growing cognitive capacities and have trouble with systematic decision making (Elkind, 1984). Third, they may have been punished by parents for independent decision making when this led to problematic behaviors in the past.
“Apparent competence” refers to the tendency of others to misperceive clients with BPD or borderline/suicidal characteristics as more competent, effective, and in control, and less in need of help, than they actually are. Generally such misperceptions are due to one of two problems: (1) The verbal expressions of difficulty and vulnerability are not synchronous with the nonverbal expressions of control and calmness, and an observer assumes that the nonverbal messages are more accurate than the verbal ones; and (2) competence in one set of situations or when certain people are nearby does not generalize to other situations. Apparent competence contrasts, of course, with the opposite pole of active passivity. That is, it contrasts with the alternate presentation within the same individual of having few areas of competence and strongly requesting help. This contrasting presentation often earns such clients the label of “manipulative.” Apparent competence stems largely from the fact that emotionally vulnerable individuals are more competent within some affect states than others. Since their moods shift substantially and unpredictably, the competence of such individuals likewise shifts rapidly and with little warning. Teenagers’ increased moodiness, combined with an emerging but as yet unstable identity, means that shifting affective and behavioral patterns are to be expected. In addition, clients with BPD or borderline features have often not learned how to communicate effectively about a need for help, and also tend to fare better in emotion regulation within the context of a supportive, secure relationship. Since the therapy relationship often provides such a setting, a therapist may not have access to the full range of affective dysregulation within a client’s repertoire.
To summarize this second dialectical dilemma, it involves shifts between the extremes of helplessness on the one hand, and exaggerated or inaccurately assessed competence on the other. In dealing with this pattern, the therapist needs to be able to recognize and reinforce the client’s actual areas of competence, and not the client’s extreme helplessness. At the other extreme, the therapist needs to avoid developing unrealistic expectations about the client’s competence level and thus disregarding minor indications of distress. Table 5.4 summarizes this dialectical dilemma, together with its treatment targets and useful techniques and strategies.
One of the central goals of DBT is to increase clients’ active problem-solving ability and expand their repertoire of effective coping strategies. At the same time, clients need to be more motivated to use these new strategies and to communicate more accurately when they do and don’t need help. DBT addresses this goal through increased reliance on clients’ behavioral skills. For example, mindfulness skills such as accessing “wise mind” (see Chapter 10) help clients to identify needs and determine what they need to do to achieve their objectives. Interpersonal effectiveness skills help clients assert their needs more effectively. Contingency management procedures increase clients’ motivation to rely on their own abilities, and behavior analysis and solution analysis strategies increase their problem-solving capacity.
TABLE 5.4. Targeting Active Passivity versus Apparent Competence
In the next pair of treatment targets, the first one involves teaching clients to become more adept at communicating emotional states, recognizing and anticipating vulnerabilities, and asking for help appropriately. The second one involves teaching clients how to disengage mood from behavior—a central goal of DBT skills. This ability requires practice in mindfulness, emotion regulation, and distress tolerance skills.
Among adolescents, the dialectical dilemma of unrelenting crises versus inhibited grieving involves the contrasting behavior patterns of either immediate, impulsive escape from emotional pain or pervasive avoidance of emotional pain. The term “unrelenting crises” (i.e., “crisis-of-the-week syndrome”) describes a pattern of responses in which an initial precipitant evokes intense emotional pain, which the client then escapes through impulsive actions because of an inability either to tolerate or to diminish this pain. The combined consequences of impulsive behaviors, emotional vulnerability, and faulty interpersonal relations create conditions for encountering additional aversive events. The unrelenting nature of these aversive events hinders the ability to recover fully from any one stressful event, trapping the client in a vicious cycle in which he or she becomes more vulnerable to further emotion dysregulation. Even normal adolescents may appear to present a pattern of unrelenting crises, as adolescents’ thinking is characterized by egocentrism, including the subjective sense that they are continually “on stage” and remain the focus of others’ attention. The belief in this self-directed attention, referred to as the “imaginary audience,” contributes to adolescents’ self-consciousness, self-focusing, and nearly obsessive concern with appearance and behavior (Lapsley, 1991). It is also thought to contribute to adolescents’ strong desire for privacy and low threshold for regarding parents’ solicitations as intrusive. Another aspect of adolescents’ egocentric thinking involves the “personal fable,” or the belief that no one can understand their experiences or their emotional life, such as being in love. As such, everyday events may be related with a sense of high drama. Along with believing that their experiences are unique comes a sense of feeling special and invulnerable, which may relate to such adolescent risk-taking behaviors as experimentation with substances, sexual promiscuity, risky automobile driving, or criminal behavior (Lapsley, 1991). In general, impulsiveness increases at this time (CDC, 1995). Yet these behaviors, along with increased conflict with parents, moodiness, and impulsiveness, may set the stage for actual crisis situations, and a therapist must assess them (rather than assuming that they are just examples of an adolescent acting like an adolescent).
Note also that some adolescents are simply unlucky, and have chains of crises occur through factors not of their own making. For example, being born into poverty and not having supportive adults in one’s life are circumstances that will in themselves generate crises. Yet much of the approach to targeting unrelenting crises (see below) will apply, regardless of whether an adolescent generates crises through his or her own actions.
In contrast with this tendency to move rapidly from crisis to crisis, individuals with BPD or borderline features also tend to avoid the full emotional processing of intensely painful losses or traumas. “Inhibited grieving” refers to involuntary, automatic avoidance of cues that evoke past losses and trauma, in which individuals shut down the natural progression of normal stages of grieving, and thus never become habituated to the sadness associated with loss and grief, as well as to anger, shame, and other painful emotions. Since everyday life provides frequent cues of loss, these clients enter a vicious cycle in which they become exposed to loss cues, begin mourning, interrupt this process by automatically avoiding the cues, become exposed to additional loss cues, and so on. For teens, avoidance of emotional processing may be facilitated by distractions such as peer group involvement, substance use, or experimenting with a variety of high-risk behaviors (CDC, 1995; U.S. Department of Health and Human Services, 1994; Zuckerman, 1979).
To summarize this third dialectical dilemma, it involves vulnerability to the unrelenting crises occurring in a client’s life at one extreme, and at the other, overly inhibiting the affect related to these crises. Thus the client often fails to elicit needed social support and often handles the crises through impulsive behaviors designed to blunt painful emotions. The therapist’s dialectical dilemma entails providing balanced responses to the fluctuating displays of intense affect or completely inhibited affect. Table 5.5 summarizes this dialectical dilemma, its associated treatment targets, and specific techniques and strategies.
The first two DBT targets for this dialectical dilemma are to decrease crisis-generating behaviors and to increase realistic decision making and judgment. These targets are based on the assumption that individuals with BPD or borderline characteristics participate in generating the crises they experience, through engaging in mood-dependent behaviors and having difficulty predicting realistic outcomes of those behaviors. Approaches to these behaviors include increasing consequential thinking (e.g., “If I curse out the teacher and storm out of the classroom, I’ll probably get suspended, which would lead to lots of other problems”); mindfulness skills to practice observing emotional states and action urges rather than acting on them; emotion regulation skills to change extreme emotional reactions; and distress tolerance skills to avoid impulsive responding to emotional distress. In addition, DBT insight strategies address these behavioral targets by highlighting dysfunctional patterns involving faulty judgment and decision making. Teens possess the ability to benefit from these interventions because of their increases in hypothetical reasoning, ability to view situations from more than one angle, and capacity for self-regulation (Elkind, 1984; Overton, 1991; Romaine, 1984). Along with the capacity for abstract reasoning comes further development of moral principles: Teens are beginning to move from reward- and punishment-based moral choices to a more principled and abstract morality, informed by increased perspective-taking ability (Kohlberg, 1984). (However, it should be noted that few individuals actually reach the highest stages of moral development proposed by Kohlberg.)
TABLE 5.5. Targeting Unrelenting Crises versus Inhibited Grieving
| Dialectical pattern | Secondary treatment targets | Specific techniques/strategies |
| Unrelenting crises (immediate, impulsive escape from emotional pain) | Increasing realistic decision making and judgment; decreasing crisis-generating behaviors | Increasing consequential thinking Mindfulness practice in observing emotions and urges, rather than acting on them Emotion regulation skills to change extreme emotional reactions Distress tolerance skills to avoid impulsive responding to emotional distress Increasing insight into dysfunctional patterns |
| Inhibited grieving (pervasive avoidance of emotional pain) | Increasing emotional experiencing; decreasing inhibited grieving | Exposure to rather than inhibition of/escape from negative emotions |
| Mindfulness to current emotional states without changing them | ||
| Distress tolerance skills of self-soothing, distracting, or radically accepting the emotion | ||
The second part of targets involves increasing clients’ ability to experience sadness and other negative emotions as they occur, rather than inhibiting them. This ability is a critical aspect of reducing both the intensity of these emotions and the impulsive behaviors that are likely to result from pervasive yet ineffective attempts at blocking them. The central approaches to addressing the targets involve exposure procedures, such as practicing mindfulness to current emotional states without changing them. Or clients can employ distress tolerance skills, including self-soothing, distracting, or radical acceptance of the emotion, to help them modulate and thereby tolerate the distress without acting impulsively to escape from it.
Linehan’s (1993a) original set of dialectical dilemmas and secondary targets remain applicable to the treatment of adolescents—as do other behavioral extremes she identified, such as skill enhancement versus self-acceptance, transparency versus privacy, trust versus suspicion, emotion control versus emotion tolerance, and self-focusing versus other-focusing.
However, we subsequently found that in work with suicidal adolescents and their parents, additional dialectical dilemmas specific to this family constellation become apparent. The parents of suicidal adolescents, the adolescents themselves, and even the treating therapists commonly vacillate and become polarized along three dimensions:1
Excessive leniency versus authoritarian control
Pathologizing normative behaviors versus normalizing pathological behaviors
Fostering dependence versus forcing autonomy
Parents, the therapist, and the adolescent can all vacillate between being excessively lenient and being authoritarian. “Excessive leniency” refers to making too few behavioral demands of adolescents (or to adolescents’ making too few demands on themselves). One way that parents display excessive leniency involves capitulation to an adolescent’s demands. In this style of excessive leniency, parents of a suicidal adolescent relinquish many of the rules or standards that they would ideally apply, or that they actually do apply to their other children. Thus they defy their own values, or they apply different rules to different children. Many parents report feeling coercively controlled (e.g., Patterson, 1976) by their children’s suicidality and emotion dysregulation, making statements such as “I know the stakes are too high if I say no and get her angry, so I just let her stay home from school,” or “She says the smoking calms her down and there’s always the threat of suicide, so I buy her cigarettes,” or “I feel like I’m always walking on eggshells, so I let him go out with his friends until all hours, because it’s better than the consequences of telling him he can’t go.” Although they may indulge their adolescents, these parents report often feeling conflicted, restrained, guilty, and resentful, unsure of themselves and their parenting decisions. Adolescents’ increased tendency to argue and criticize endlessly (Elkind, 1984) only intensifies these feeling of defeat.
Excessive leniency may also be demonstrated through a laissez-faire style of parenting. This excessive permissiveness typically occurs in the context of parents’ raising several children with little help, which often results in a rather chaotic household. In such cases, parents may acquiesce to adolescents demands because it requires the least effort in the moment. Or adolescents may do whatever they wish in the absence of parental supervision. Both the capitulation and the laissez-faire expression of excessive leniency may be in part a result of adolescents’ reinforcing ineffective parenting and punishing effective parenting.
Adolescents themselves face similar conflicts with excessive leniency, often pushing their environments to let them live according to their own standards, but then later facing negative consequences due to this lack of controls on their behavior. Although initially gaining what they want, they may face increased emotion dysregulation as a result (e.g., through consequences of their actions, such as disrupting their sleep schedules or missing classes and then failing a test). Those whose parents exhibit a laissez-faire parenting style may frequently behave in a reckless manner without any model for negotiating the difficult situations in which they consequently find themselves. In addition, these adolescents may experience some degree of anxiety or disappointment in response to this lack of parental supervision. Following a period of few or no externally imposed or self-imposed controls (and the resulting negative consequences), an adolescent, parents, and/or other involved authority figures will commonly flip to the other extreme of overly tight controls on the adolescent’s behavior. This represents a move to the authoritarian control pole of the dilemma.
“Authoritarian control” refers to holding tight reins on behavior, by coercive methods of limiting freedom, autonomy, and independent decision making. This pattern might include enforcing overly strict or even unrealistic rules about curfew, contact with boyfriends or girlfriends, schoolwork, or even TV watching. Parents of adolescents often attempt to hold tighter reins as their children mature physically and cognitively, demand more autonomy, and experiment with new behaviors to fit their more adult-like bodies and minds. Yet these controls can become extreme in parents who are desperate to suppress the behavioral dysregulation in their suicidal adolescents with BPD or borderline features. Parents may apply hasty punishments or novel rules that are excessive and unlikely to be carried out (e.g., “You are grounded until the end of the school year”). Or adolescents, especially within the suburban population, will similarly apply such unrealistic punishments to themselves (e.g., “I won’t watch any TV after school until after the next marking period, so I can get my grades up”). When these extreme methods of exerting control fail, are violated, or are given up on, parents and adolescents alike seem to become demoralized and commonly revert to an excessively lenient approach.
The behavioral extremes described here closely parallel Baumrind’s (1991a) childrearing dimension of “permissiveness–restrictiveness” in her research on parenting styles. Perhaps because of the strikingly labile nature of mood and behavior in suicidal adolescents with borderline features, we have observed a tendency for parents of such adolescents to vacillate between these two extremes, rather than to adhere consistently to one style. Even if parents stably exhibit tendencies toward one end of the pole or the other, they frequently switch to the opposite pole when a crisis arises or when they are feeling ineffective and demoralized. Moreover, overly permissive or overly restrictive (i.e., authoritarian) parenting styles have been linked with more negative child outcomes (e.g., Baumrind, 1991b; DeKovic & Janssens, 1992), and may comprise part of DBT’s theorized environmental contribution to the etiology of BPD or borderline features. This may especially apply in situations in which such styles prove a particularly poor fit with children’s temperaments or needs. In other words, somewhat extreme parenting styles along this dimension may contribute to negative child outcomes, while problematic child outcomes may contribute to rendering parents’ styles more extreme.
To summarize this dialectical dilemma, for parents it involves vacillating between the extremes of being overly permissive with their adolescents (and feeling ineffectual, coerced, and partly responsible for the adolescents’ continued difficulties) on the one hand, and setting unreasonable, overly restrictive limits on the other (often to compensate for a period of perceived overpermissiveness). The parents face the quandary of not reinforcing maladaptive behavior while not stifling normal development. For example, parents may wonder whether they should permit marijuana use by a 17-year-old because it serves as an effective soothing mechanism in lieu of self-cutting, or whether they should give in when other demands are linked with suicide threats.
This dialectical dilemma for the adolescent involves the question “When do I let myself off the hook, and when do I buckle down?” For the therapist, the dilemma involves balancing supporting the parents in enforcing effective limits while exhorting them to reinforce small improvements and to allow a reasonable level of freedom. For example, a parent must recognize a C+ as improvement when past grades were failing, instead of grounding an adolescent for not making the honor roll. The therapist also needs to support the adolescent in adhering to limits, as well as in rewarding him- or herself for small accomplishments. Table 5.6 summarizes this dialectical dilemma and its associated treatment targets and strategies/techniques.
The first pair of targets for this dilemma involves establishing a reasonable degree of parental authority (or self-discipline) while reducing excessive leniency. In fact, what Baumrind (1991a, 1991b) has labeled the “authoritative” parenting style offers a useful model for an effective middle ground for parents in this domain. The authoritative style of parenting consists of high restrictiveness and high demands for mature behavior, balanced with demonstrations of reasoning, support, love, and respect for the child’s viewpoint. Children raised in this fashion tend to show good outcomes in peer socialization, school performance, self-reliance, and self-esteem (Baumrind, 1991b; Dumas & La Freniere, 1993).2 And parents who learn authoritative parenting methods can still be satisfied that they can exert some control over their children (as opposed to feeling they must surrender authority to appease the volatile adolescents).
TABLE 5.6. Targeting Excessive Leniency versus Authoritarian Control
| Dialectical pattern | Secondary treatment targets | Specific techniques/strategies |
| Excessive leniency (placing too few behavioral demands or limits on the adolescent’s behavior) | Increasing authoritative discipline; decreasing excessive leniency | Balancing restrictiveness and demands with reasoning, love, and respect Providing clear rules; rewarding desired behavior, along with establishing consequences for not following them (contingency management strategies) Following “wise mind” values in placing limits; using interpersonal effectiveness skills to communicate with teens |
| Authoritarian control (placing overly tight controls on the adolescent’s behavior) | Increasing adolescent self-determination; decreasing authoritarian control | Rewarding effective behaviors while minimizing excessive rule setting, punishments, and coercive control strategiesbehavior) |
| Using interpersonal effectiveness skills in discussions with teens, rather than unilateral, inflexible rules | ||
Ways of increasing the characteristics of an authoritative parenting style include an emphasis on rewarding (and thus shaping and maintaining) desired behavior; providing clear rules and expectations, along with consequences for not following them; and enforcing the rules and consequences consistently. Therapists can work with parents on these issues primarily during as-needed family sessions, although some of these points can also be worked into discussions within multifamily skills training groups. Consequences should not be excessive to the point of being unlikely to be carried out. Yet teaching parents the behavioral principle of “correction–overcorrection” can be useful for applying consequences to adolescents. In correction–overcorrection, a parent applies a consequence that either withholds something that an adolescent wants or adds an aversive condition. Next the parent has the adolescent engage in a behavior that not only corrects effects of the maladaptive behavior, but goes beyond this to overcorrect its effects (Linehan, 1993a). As soon as the correction and overcorrection are completed, the initial consequence is removed. The consequence should relate to the problem behavior and ideally teach the adolescent client something as well. For example, if a newly licensed adolescent “borrows” the parents’ car without permission and gets into a fender bender, the parents might withhold driving privileges, then ask the adolescent to pay for the damage (correction), and then apply new rules involving much closer monitoring of the adolescent (e.g., earlier curfews, frequent phone calls, etc.) for 1 month (overcorrection). These consequences would hold the adolescent responsible for the damage to the car (teaching responsibility) and also require a temporary increase in communication and decrease in autonomy. Upon the adolescent’s taking care of the damage and abiding by the agreements of 1 month’s increased supervision, access to the car would be reinstated. An important factor to consider in applying consequences is what was lost or damaged by the egregious behavior. Ideally, whatever was lost in the infringement needs to be repaired. In this example, both the car and the parents’ trust have been damaged; the consequences are thus intended to repair both.
In addition to enhancing parents’ authoritative parenting, therapists can also teach parents to follow their “wise mind” values in determining which behaviors to restrict or permit; teach them the principle of observing their own limits (since if they do not, parents, much like therapists, are likely to feel resentful, overwhelmed, burned out, and ineffective); and emphasize the use of interpersonal effectiveness skills in communicating with adolescents in a way that helps parents attain their objectives while maintaining the relationship and keeping their self-respect. Other interpersonal effectiveness skills lend additional support, such as identifying thoughts that interfere with effectiveness (e.g., “This will never work”) and identifying factors to consider when considering interpersonal objectives with an adolescent child (e.g., “Is this a good time?”, “Does she have the capability to give me what I am asking for?”).
For adolescents, these targets involve applying similar contingency management strategies in self-discipline, including favoring reward over punishment as a method of influencing their own behavior. They also need to set realistic goals for and apply realistic consequences to their behavior. For example, rather than canceling all social plans for an entire marking period (a strategy bound to be abandoned), the adolescent might try building in small, frequent rewards for movement toward goals (e.g., completing 2 hours of homework before turning the TV on). We should note that many teens in our inner-city population have trouble with this model of self-reinforcement. Because of exposure to violence and other traumas, many such adolescents have a sense of a foreshortened future and other pessimistic views. The concept of delayed gratification may prove hard to sell. But therapists can also work with adolescents individually, teaching enhanced judgment, planning, and decision-making skills (e.g., using distress tolerance skills to reduce impulsive responding, and then considering likely consequences of various behavioral choices). Furthermore, adolescents can benefit from the practice of accepting and tolerating parental inconsistency.
One of our cases concerned a 17-year-old boy who would come home drunk and past curfew. At some times when he did this, his parents would not outwardly respond, to avoid creating a scene. They nevertheless remained concerned and angry about it. At other times, for similar transgressions, they would unpredictably lose their tempers and punish him excessively, due in part to feeling impotent and exploited. They would think, “We are tolerant and let him get away with murder, and instead of appreciating it and behaving according to the rules, he takes advantage of us.” The goals in this case were to encourage parental communication of rules and expectations, as well as consistent and appropriate discipline (e.g., “The punishment should fit the crime”). Importantly, the parents also needed to become familiar with principles of shaping, and to reward their son for progress in adhering to rules. Therapists have sometimes found themselves in the precarious position of nearly invalidating parents and oversimplifying dilemmas while trying to help them to find a middle path in this area. For example, a parent may say, “How could I have insisted she go to school that day? I had to get to work myself, and I just could not have dealt with an explosion at that point!” On the other hand, “How can I not insist she attend school? There are only 2 months left in the school year, and she’s in danger of not graduating!”
The next pair of targets involves establishing a reasonable degree of parental permissiveness without having parents abdicate all parental authority or neglect the adolescent’s needs for external controls. As with the targets of increasing authoritative discipline and decreasing excessive leniency, an effective middle ground for parents consists of working toward more of an authoritative style of parenting. In particular, ways for parents to increase an adolescent’s self-determination and reduce authoritarian control include rewarding instances of the adolescent’s effective behaviors while minimizing excessive rule setting, application of punishments, and coercive control strategies (such as nagging, yelling, hitting, or inducing guilt). In place of unilateral rules, the therapist can work with parents to increase their use of interpersonal effectiveness skills with the adolescent to communicate behavior preferences with explanations of positive or negative consequences (“I’d like it if you did this, because…”). This approach not only grants adolescents more jurisdiction over their own behaviors, but also allows parents to model important aspects of effective functioning, such as skillful communication and consideration of consequences. For adolescents, increasing self-determination and decreasing an authoritarian style of self-control primarily involve self-applied contingency management strategies—a significant challenge for many of our teens.
We define “pathological behaviors” as extreme manifestations of developmentally normative behavior that are also likely to harm an adolescent’s quality of life or physical well-being in the long run. For example, rather than experimenting with marijuana at a party, an adolescent becomes involved in selling it at school; rather than experimenting with sexuality, an adolescent engages in unprotected sex that results in an unwanted pregnancy or in contracting HIV, or becomes subject to a gang rape after drinking excessively in a dangerous situation; rather than yelling at her parents and storming out of the room, an adolescent fights with her parents and ingests a bottle of pills.
Distinguishing between normative and pathological behaviors may become especially confusing for parents, since several behaviors typical of adolescents are also characteristic of BPD. These include unstable identity, a variety of high-risk behaviors, relationship instability, and emotional lability. Thus it may be difficult to distinguish behavioral patterns indicative of pathology from those falling within developmental norms for adolescents. Developmentally normative adolescent behaviors include those that are commonly observed and reported within the teenage years (e.g., experimentation with drugs, alcohol, and sexuality; changing goals or self-image; frequent breakups of romantic relationships; interpersonal conflicts, particularly with parents; moodiness), but that do not result in self-harm, hospitalization, school dropout, or other life-threatening or severe quality-of-life-impairing consequences.
To summarize this dialectical dillema, for the parents it involves recognizing and allowing normative adolescent behaviors, while at the same time identifying and addressing those behaviors that are linked to severe dysfunction or negative consequences. This may pose a formidable challenge, as parents’ judgments of what behaviors are “dangerous” or “abnormal” have become steadfastly colored by the shadow of past suicide attempts or hospitalizations. On the one hand, it may be easy for parents to fear and restrict developmentally normative behaviors, since they may view them as linked with high-risk situations or severe consequences in their children. For example, one father granted that it is typical for adolescents to experiment with alcohol with friends, but remembered that when his son recently drank, he also drove, got into a car accident, and got arrested. Another parent realized that kids miss school on occasion because of illness, but feared that her daughter’s asking to stay home one day because of a migraine signaled a depression relapse; the previous depressive episode had begun with her daughter’s finding reasons to stay home (and had ultimately led to a suicide attempt and hospitalization). A third parent could not determine whether her daughter’s skipping classes in late spring reflected normal “senior-itis” (her daughter asserted that everyone was doing it) or the return of impulsive behaviors and ineffective judgment. Adolescents who have greatly improved after an initial suicidal crisis have at times complained that their parents have unrealistic expectations, and, rather than acknowledging their progress, require them to behave as “perfect teenagers.”
On the other hand, parents of suicidal adolescents with BPD or borderline features may (1) become so desensitized to at-risk behaviors that they overlook signs of danger or dysfunction, or (2) knowingly ignore harmful behaviors because of relief that they are less harmful than other behaviors the adolescents have exhibited previously (e.g., accepting school truancy because an adolescent is no longer slashing her arms with a razor).
For the adolescent, this dialectical dilemma similarly involves recognizing normative versus pathological behaviors. Suicidal adolescents in treatment often fluctuate between second-guessing seemingly normative behavior patterns (e.g., “I failed my first road test—do you think this means I’m all screwed up?”) and rationalizing clearly problematic and dysfunctional behavioral patterns (e.g., “I had to fight her ’ cause she gave me a dirty look”). For the therapist, the dialectical dilemma involves maintaining as objective a view as possible of what constitutes normative versus non-normative adolescent behavior in general. It further involves noting which questionable behaviors have not been functionally related to other dysfunctional behaviors for a particular client and which behaviors have proven maladaptive for this client. For example, spending the night at a friend’s house might be anything from beneficial to dangerous, depending on the nature and history of the relationship with the friend. Even therapists are susceptible to targeting developmentally normative behaviors on the basis of links that indicated dysfunction in the past but may have changed (e.g., arguing with a parent may no longer be an antecedent to self-injurious behavior or urges). Therapists may also become desensitized to maladaptive behaviors that are lower in magnitude than past behaviors (e.g., conflict with a parent may still be severe and adversely affecting quality of life, but goes unnoticed by the therapist as a target because it no longer escalates into violence toward the parent). Moreover, a therapist must take care not to impose personal values while determining session targets from the diary card, but instead must assess for behaviors that are functionally related to treatment targets. Issues that particularly tend to challenge a therapist’s objectivity include teenage sexuality (e.g., abstinence, birth control, parenthood, abortion), substance use, nicotine use, gang membership, education, body piercing and tattoos, and use of physical force in self-defense. Table 5.7 summarizes this dialectical dilemma and its treatment targets.
Increasing parents’ or adolescents’ recognition of developmentally normative behaviors while decreasing the pathologizing of these behaviors involves a combination of techniques. Psychoeducation on normative adolescent behaviors is used, and the therapist also encourages “wise mind” judgments about whether the behavior in question seems like what adolescents typically do. Handout C.5 in Appendix C provides examples of normative adolescent behaviors and of behaviors that are cause for concern. The therapist must also consider whether the behavior in question was carried out impulsively or dangerously, and assess whether the behavior is functionally linked with a target-relevant maladaptive behavior.
TABLE 5.7. Targeting Pathologizing Normative Behaviors versus Normalizing Pathological Behaviors
| Dialectical pattern | Secondary treatment targets | Specific techniques/strategies |
| Pathologizing normative behaviors (viewing developmentally normal adolescent behaviors as deviant) | Increasing recognition of normative behaviors; decreasing pathologizing of normative behaviors | Psychoeducation about normative teen behaviors Considering whether behavior in question is functionally linked with target-relevant maladaptive behaviors For teens, accepting parents’ fears/ reactions and repairing or overcorrecting behaviors |
| Normalizing pathological behaviors (failing to address or perceive deviant adolescent behaviors as such) | Increasing identification of pathological behaviors; decreasing normalization of pathological behaviors | Psychoeducation “Wise mind” judgments of normative nature of behaviors Evaluation of risk level, as well as links with dysfunctional behaviors |
Adolescents may also be taught to work toward accepting their parents’ tendency to make too much of what seems like “normal teenage behavior” to them. Therapists can explain to their adolescent clients that when a teen’s behavior has reached an extreme (e.g., suicide attempt, school suspension, or unwanted pregnancy), it is typical for adults to hold this individual to stricter standards than others, even after the teen has shown improvement. Thus adolescents may have to (1) practice distress tolerance skills while their parents are applying overly demanding or perfectionistic standards; (2) use interpersonal effectiveness skills to ask for what they want and negotiate a way both to attain their goals and to address/allay their parents’ concerns; and (3) overcorrect their own behavior to earn back their parents’ trust and acceptance.
Increasing parents’ or adolescents’ identification of pathological (i.e., harmful) behaviors involves psychoeducation (e.g., educating an adolescent girl about risks of unprotected sex when she is normalizing it, saying that her boyfriend prefers it that way). Decreasing the normalization of harmful behaviors also involves “wise mind” judgments about the normative nature and comfort level of particular behaviors (e.g., encouraging the just-mentioned adolescent to follow her “wise mind” evaluation about performing a sexual act that feels coerced, despite her boyfriend’s protestations that it is “no big deal”). “Wise mind” also encourages evaluations about the impulsiveness or risk level of a behavior. The therapist can point out that a client’s decision occurred rashly and without consideration of consequences—for example, when a client challenges, “So what’s the harm in quitting my after-school job? People quit jobs every day!” The therapist should consistently assess the behavior’s functional links with target-relevant maladaptive behaviors (e.g., a link between a client’s spending “normal” time with a boyfriend after school and consistently coming late to therapy appointments). The therapist’s application of in-session behavioral analyses affords ample opportunities to address this target. Helping the client to recognize maladaptive behavior patterns and unwanted consequences can help in reducing the normalization of non-normative behavior.
“Fostering dependence” refers to acting in ways that serve to stifle an adolescent’s natural movement toward autonomy. This may include parents’ overt attempts to block a teen’s independent functioning and growth, or more subtle actions that result in reduced autonomy. Parents may naturally attempt to monitor and maintain communication with their adolescents as the teens assert independence and engage in more risky behaviors. Yet the tendency to foster dependence is often extreme in parents of adolescents who have been suicidal, out of fear that loosening their grip will reduce their ability to protect their children and result in more harm to them. In addition, some parents report having developed an intense, special bond with an adolescent child as a result of seeing the teen through suicidal crises and then joining him or her in treatment (i.e., the multifamily skills training group), although this usually entails the exclusion of other siblings who do not share in this experience. For the adolescent, fostering dependence may include clinging to parents by behaving in an overly needy manner. Such clinginess may occur because of the suicidal adolescent’s deep sense of self-doubt and lack of self-confidence.
One way that fostering dependence may manifest itself is through excessive caretaking by parents, to the extent that an adolescent does not learn to negotiate the world on his or her own. For example, one adolescent was experiencing increasing conflict with a teacher, had gotten to the point of yelling and cursing at her, and was expressing misery about these events to her mother. Her mother stepped in and, after a series of meetings with school personnel, arranged for her daughter to drop the class and receive individualized tutoring in the subject in its place. The mother reported her conflict about having intervened in this manner. On the one hand, she realized she had not let her daughter face the natural consequences of her actions; nor had she allowed the daughter to negotiate the situation on her own and possibly repair the relationship with the teacher, thus building mastery. On the other hand, she had been afraid of the potential consequences of continued problematic interactions with the teacher; moreover, she had been afraid of her daughter’s increasing emotion dysregulation as school was becoming more stressful. Rather than risk a recurrence of suicidal behavior and hospitalization, this mother understandably took the immoderate step of terminating interaction with the teacher as rapidly as possible.
“Forcing autonomy,” on the other hand, involves parents’ severing (or at least strongly loosening) the ties with their adolescents, in such a way that the adolescents are thrust toward separation, greater self-sufficiency, and a more adult level of functioning. It might include kicking the adolescents out, or demanding that they earn the money required to support themselves. Although it is expected that adolescents will gradually increase their autonomy and reduce reliance on parents, this can occur to an extreme degree within the population of suicidal adolescents with borderline features. Parents of such teens will at times essentially push the adolescents toward independence or reject them, as a result of either giving up, feeling exasperated and burned out, or believing that such a push is needed to get the teens to “grow up” and “start taking some responsibility.” Examples of this tendency are reflected in statements such as “Well, then, find a way to pay for therapy yourself!”, “Fine, then don’t come home at all!”, and “You call up the principal and explain this!” At times forced autonomy can take the form of excessive responsibility thrust upon an adolescent (e.g., responsibility for feeding, washing, and dressing four younger siblings each morning before school; such parental directives are not uncommon in some of our families, where single parents are raising several children).
At the same time, adolescents may force their own autonomy by letting go too fast or too extremely. This may be the result of an impulsive reaction to conflict, a desire to prove themselves, a result of life circumstances their actions have created (e.g., becoming pregnant and moving in with a boyfriend), or trouble in regulating emotional distance with a parent. As an example of this last pattern, one of our adolescents, who was rather withdrawn and lacking in self-confidence, would go for a period of time depending on her mother for social companionship—accompanying her to movies, shopping, ball games, and so on, confiding in her all the while. After a while, she would get disgusted and fed up with her mother (they often argued), as well as humiliated that at age 17 she needed to rely on her mother as a friend. She would then flip to the other extreme—pushing her mother away, shutting her out of her life, and experiencing her as intrusive if she even asked how her day was. After a period like this, she would inevitably feel both guilty and alone, and would again revert to the dependent extreme of this behavioral dimension.
To summarize this dialectical dilemma, it necessitates the parents’ finding the middle way between clinging or caretaking to the point of stifling the adolescent’s individuation process, and pushing away or letting go precipitously. For the adolescent, it entails achieving a balance between an effective and comfortable degree of relatedness and dependence on the one hand, and an effective and comfortable degree of separation, individuation, and identity formation on the other. For the therapist, the dialectical dilemma concerns not only guiding the adolescent in finding a balanced level of dependence on and autonomy from parents, but in monitoring his or her own tendency to foster extreme dependence versus extreme self-reliance in the adolescent vis-à-vis the therapeutic relationship. Table 5.8 summarizes this dialectical dilemma and associated treatment targets and strategies.
The targets of increasing individuation and decreasing excessive dependence involve teaching parents to balance consultation to their children in how to negotiate their environments with direct environmental interventions. This notion derives from the DBT concept of consultation to the patient (see Chapters 3 and 4). Thus, rather than stepping in and taking over a situation to spare an adolescent environmental consequences or emotion dysregulation, parents can work toward instructing or coaching the adolescent in negotiating and mastering difficult situations, while still intervening when essential.
Similarly, the therapist can encourage adolescents themselves to consult with appropriate adults (e.g., parents, teachers, guidance counselors, relatives, the therapist) about handling difficult situations, rather than behaving in a helpless manner and imploring others simply to handle the situations for them (i.e., acting in an actively passive manner—the opposite of acting to build mastery, a necessary component of emotion regulation). Although an adolescent might become overwhelmed and thus emotionally dysregulated in the face of a challenging situation, the therapist might coach the adolescent to get into “wise mind,” evaluate the situation, and plan an effective course of action, even if this includes soliciting the help of others. Critical problem-solving skills (e.g., generating alternatives to impulsive behaviors, thinking through consequences, and enhancing general behavioral skills) all apply to these targets. The therapist can point out to the adolescent the long-term advantages of working toward competent self-reliance, such as being taken seriously when the adolescent wants to be, earning more privileges, and reducing emotional vulnerability while increasing a sense of mastery and building a life worth living.
TABLE 5.8. Targeting Fostering Dependence versus Forcing Autonomy
| Dialectical pattern | Secondary treatment targets | Specific techniques/strategies |
| Fostering dependence (stifling the adolescent’s natural movement toward autonomy) | Increasing individuation; decreasing excessive dependence | Balancing consultation to teens on how to act with direct environmental intervention Encouraging teen to consult with adults and make “wise mind” evaluations of how to handle situations Increasing teens’ problem-solving skills Building parents’ social support networks |
| Forcing autonomy (thrusting the adolescent toward separation and autonomy prematurely) | Increasing effective reliance on others; decreasing excessive autonomy | Regulating distance between parent and adolescent, rather than going to either extreme (by using distress tolerance, emotion regulation, and interpersonal effectiveness skills) |
| Pointing out to teen the notion of effective reliance on others (rather than the concept of dependence) | ||
Parents’ dependence on their adolescents may be heightened because of the social stigma and isolation they often feel as parents of children who have made suicide attempts or who have features (or a full diagnosis) of BPD. Some of these parents have reported that no one in their lives understands what they experience on a day-to-day basis; to make matters worse, they feel they cannot confide in friends or family members, because these others will conclude that they are horrible parents. Thus the therapist may encourage parents to enhance social support through support groups, friends they can trust, or even other parents in the multifamily skills training group. To some degree, this happens naturally; in fact, in one of our suburban populations, a group of mothers started meeting each other for dinner monthly.
The targets of increasing effective reliance on others and decreasing excessive autonomy involve the parents’ and adolescent’s remaining connected enough to enhance effective outcomes for the adolescent. Although adolescents have entered a developmental stage that involves a natural quest for separation and individuation from parents, they lack the experience and judgment to negotiate situations entirely on their own. The therapist can make the assumption that adolescents with suicidal behaviors or borderline features lack critical behavioral capacities as well. Specific interventions here include working toward regulating the amount of distance between parents and adolescents (i.e., thwarting the tendency to exhibit one behavioral extreme as a reaction to another; this may require distress tolerance and emotion regulation skills) and enhancing interpersonal effectiveness skills between parent and child (so that parents can offer and adolescents can ask for guidance; also, forced autonomy often occurs following a severe conflict between an adolescent and a parent). The therapist might point out to the adolescent the ultimate advantages of increasing effective reliance on others (gaining needed help while preventing further emotional vulnerability), as well as the maturity it takes to recognize when one needs help and to ask for it.
Because adolescents typically reside with their parents and the parents participate in therapy, the adolescent dialectical dilemmas and corresponding treatment targets apply to parents as well as to therapists and clients. Interestingly, an additional tendency we have observed with this population is polarization between parents along the dialectical dimensions (especially in our suburban Long Island University population, where both parents are often involved in treatment). That is, parents are at times polarized along the dimensions of excessive leniency versus authoritarian control, pathologizing normative behaviors versus normalizing pathological behaviors, or fostering dependence versus forcing autonomy. This polarization has presented itself in a number of forms: Parents may participate in a teen’s treatment together but adhere to divergent extremes; divorced parents may appear at different times for as-needed family sessions and present with positions in dramatic opposition to each other; or a teen may report that an absent parent’s behaviors are opposed to those of the participating parent (typically either embracing the teen’s position wholeheartedly or firmly rejecting it). Parental relationship discord is associated with youth behavior problems as either a cause, correlate, or consequence (e.g., Cummings & Davies, 1994). In addition, researchers have identified polarization as a process occurring within the interactions of discordant couples in general (e.g., Jacobson & Christensen, 1996). The parents of suicidal multiproblem teens in particular seem to struggle against each other commonly with regard to issues of firm or lenient discipline, interpretation of a teen’s behavior as pathological or normative, and encouraging versus discouraging dependence. When such polarizations have an adverse impact on an adolescent, the therapist may find him- or herself siding with one parent, feeling pulled into doing couples therapy, or spending time coaching the adolescent to manage the parents’ differences. Psychoeducational approaches can be helpful in leading parents to a middle path, such as teaching parents effective discipline strategies, educating them about developmental norms, and helping them to consider consequences of choices regarding the teen’s level of autonomy. Furthermore, looking for the grain of truth in each parent’s viewpoint and validating this is essential; working on a limited basis with parents to discuss these issues skillfully (e.g., nonjudgmentally listening to and validating each other’s viewpoints) can also help reduce extreme positions. Ultimately, the therapist’s goal might be to work with the adolescent to accept the parents’ polarities and identify the behaviors that are most effective for the teen him- or herself.
In essence, secondary targets in DBT share the overall goal with the primary targets of resolving dialectical dilemmas—that is, helping suicidal, emotionally dysregulated adolescents (and their parents) change their extreme behavioral patterns into a more balanced lifestyle. Regardless of the stage of therapy, the emphasis is on increasing the ability of adolescents and family members to “walk the middle path” and balance the many dialectical tensions inherent in their emotions, thoughts, and actions.
1We would like to express our appreciation to Laura B. Silver McGuire, who helped us formulate the adolescent dialectical dilemmas.
2This research was correlational, suggesting that we cannot conclude that this parenting style caused the observed child outcomes. Child behavior may elicit certain parenting responses, or a third factor may cause both parenting styles and child outcomes. Or, consistent with the biosocial theory of DBT, parent and child responses may co-create each other over time.