This chapter first discusses various means of assessing progress in treatment, including what to do when the therapy seems stuck. (We also offer advice on handling the devastating experience of a completed adolescent suicide.) The chapter then goes on to discuss a continuation phase of treatment in the form of a graduate group. Finally, termination from DBT is covered, emphasizing the ending of various phases of treatment (i.e., transitions) as well as formal termination from treatment.
There are several means of assessing progress in DBT; some of these involve clinical observation, and some involve formal assessment measures. Aside from the goal of assessing initial functioning and outcome for clinical and research purposes, using the formalized assessment procedures discussed in Chapter 6, a clinician is also interested in assessing progress over the course of a client’s treatment. This interest relates to the well-being of the client, the formulation of the case, and the determination of whether the client is making sufficient progress on Stage 1 targets to enter the next stage and phase of DBT. The following discussion delineates methods of using clinical judgment to assess an adolescent’s progress in DBT.
A teen client’s primary therapist continually monitors the adolescent’s progress through a number of means. These include observing changes in the diary card content, monitoring changes in therapy-interfering behavior, noting progress in individual session content, observing changes in family functioning, and obtaining feedback from the DBT consultation team. Skills trainers, pharmacotherapists, and primary therapists can all exchange relevant feedback at this meeting. The clinician thus can conceptualize the client’s progress in terms of whether the client has addressed the targets of the particular treatment stage he or she is in.
As we’ve seen in earlier chapters, the diary card records a client’s behaviors and identifies the items in the treatment hierarchy that need attention. The primary therapist uses the client’s diary card to organize the agenda of individual sessions and to drive the treatment. Thus the therapist can place a great deal of emphasis on the diary card. The way in which the adolescent complies with the diary card task also provides important information on treatment progress. A client who has had difficulty with the card has made progress if over time he or she fills out the card more accurately or more thoughtfully, fills it out completely, does it every day or nearly every day (instead of during a session or at the last minute before a session), and remembers to bring it in each week. Completing the diary card consistently throughout treatment is a demanding task. Yet we find that most adolescents do ultimately comply with this component of treatment. However, completion of the diary card does not always go smoothly, and careful attention to this can be essential for making progress in therapy. For example, one of us had an adolescent client whose entire treatment revolved around her not doing her diary card. Conducting repeated behavioral analysis of this therapy-interfering behavior was valuable, because the factors controlling the behavior were the same as those influencing her inability to initiate or complete other important tasks in her life. Each week the therapist could make an easy transition from the card to other important tasks. Another adolescent client would not complete the diary cards, and after many months of behavioral analyses, it finally came out that she primarily did not want herself or her therapist to know how many drugs she was using. Therapy progressed when the therapist first had the client fill out the card but not bring it in; then fill it out, bring it in, but get it back before the therapist read it; and finally bring it in and give it to the therapist to read.
Learning to fill out the card accurately also indicates the client’s progress. We have had adolescents who have minimized ratings on the diary card, either because they wished to downplay their problems or distress level, or because they had little insight into identifying and labeling their emotions. For instance, some troubled adolescents brought in diary cards reporting low urges to self-harm and only little emotional distress. In individual sessions, however, it became clear that the adolescents were indeed minimizing their own experiences. For such adolescents, we would consider it progress for their cards over time to reflect greater urges and indications of distress. Since this is often the case, clinicians should not be alarmed if after weeks in treatment clients who seem to have a minimizing response style appear worse on their diary cards.
For most adolescents, progress is reflected in the diary card by decreases in reported urges to commit suicide or NSIB, in actual suicide attempts or NSIB, in other impulsive target behaviors (i.e., quality-of-life-interfering behaviors recorded on the diary card, such as reductions in alcohol and drug use, unsafe sex, problems with housing, problems with school truancy, etc.), and in negative emotions. Such decreases reflect progress on Stage 1 treatment targets. An increase in ratings of positive emotions also indicates progress.
Examining a clients’ therapy-interfering behaviors is another means of assessing progress. Some therapy-interfering behaviors will involve the diary card, such as not filling it out regularly or not bringing it in to session. Other behaviors will not be reflected on the diary card, but will be displayed in the interaction with the therapist (e.g., remaining mute during sessions, throwing things in the therapist’s office, dissociating during sessions, refusing to leave the office at a session’s end, calling excessively, or calling with suicide threats and then hanging up). Therapy-interfering behaviors may cover a wide range: trouble with the therapeutic alliance, inability to regulate anger or hostile behaviors in session, arriving late to session, not completing homework assignments, not participating in the skills training group, problems with motivation, and/or not calling the therapist prior to a suicide attempt or NSIB. Patterns of therapy-interfering behaviors typically reveal themselves early in treatment; progress occurs when such behaviors subside following behavior and solution analyses. For example, in the early part of treatment one teen was self-cutting continually, but was not calling the therapist ahead of time. She simply reported the self-injurious acts on her diary card to be analyzed in the next session. Behavior analysis revealed that her lack of calling to avert the acts was mainly influenced by two factors. The first was the client’s lack of any strong commitment to work on reducing self-harm behaviors, as she found them too effective for emotion regulation. She was terrified of what her experience of misery would be if she did not cut herself. The second factor was a social phobia that included a fear of calling the therapist on the phone. For the first problem, the therapist returned to commitment strategies (linking present commitments to past commitments, examining the pros and cons of continuing to cope with distress through self-harming, etc.; see Chapter 7). The therapist and teen also used problem solving to arrive at specific distracting and self-soothing skills to replace the cutting. For the second problem, the therapist used exposure to reduce anxiety, by having the client go into the next office and telephone the therapist during session time several times in a row and initiate conversation. In addition, the therapist instructed the client to practice paging the therapist later that night (when she was presumably not in distress). Over several weeks, the client did increase her calling of the therapist prior to cutting herself. Although fully stopping her self-harm behaviors took additional time, her increases in timely calling of the therapist were considered a sure sign of progress.
The therapist can also observe progress by noting positive changes in the content of individual sessions with the client. Among such changes are improved insight and participation in conducting the behavioral analyses. In the early sessions, the client is just learning the steps of behavioral analysis, and the therapist may do most of the work while the client passively answers questions. As time passes, however, the adolescent may come in to a session ready to report the point at which the chain started, his or her vulnerability factors, the key links on the chain, and even possible solutions. For example, one adolescent male who at first had little insight into his impulsive behaviors progressed to the point where he would come to a session having completed a mental behavioral analysis himself! His therapist would attempt to write out the links in a visual chain, and he would report them so fluently that the therapist could not keep up and had to ask him to slow down. When behavior analyses go more quickly and efficiently—both because the therapist is more familiar with the client’s patterns, and because the client is developing greater insight—the therapy is progressing. Of course, if such changes are not accompanied by decreases in behaviors targeted for reduction (e.g., reduction in suicidal behaviors) or increases in behavioral skills, the therapist and client must slow down to see what important links have been missed or where solutions have been ineffective.
The therapist can also observe the client’s improvement through the session content as the content changes to reflect a progression through the DBT Stage 1 treatment targets. Since the first phase of DBT for adolescents involves the primary Stage 1 aims (see Chapter 3) of increasing safety, stability, and behavioral control, these areas will ideally show improvement as treatment progresses toward Stage 2. Obviously, improvement will be evident with decreased ratings of suicidal or self-injurious thoughts, urges, and actions, or other signs of severe behavioral dyscontrol. Thus, whereas the early treatment sessions are likely to be dominated by behavior and solution analyses of life-threatening and therapy-interfering behaviors, progress is indicated by greater attention to analyzing quality-of-life-interfering behaviors and increasing behavioral skills. For example, one of our teenagers presented for treatment in a suicidal crisis. Her suicidal urges remained for several weeks and were the focus of many sessions. However, as treatment progressed, the therapist noted that the highest-priority targets of suicidal behaviors and urges were no longer occurring, and thus session time was increasingly devoted to topics such as the client’s arguments with her parents and her efforts to secure an after-school job. In other words, as session content progresses along the hierarchy of targets, a client is moving closer to the overall aim of increased behavioral control. (Note that it is critical for the therapist to ensure that the session focus is changing in response to behavior change, and not changing even when behavior has not changed!) True progress on Stage 1 targets indicates that the adolescent is capable of moving into Stage 2 and phase 2 therapy.
DBT for adolescents directly targets the adolescents’ environment by including family members in the treatment, and it teaches skills for improving family interactions, especially between adolescents and parents. Progress should certainly be evident in improved relations and functioning between adolescents and family members. Problematic family interactions themselves often serve as a stimulus for emotional and behavioral instability for adolescent clients (and parents), or exacerbate difficulties that an adolescent (or parent) is already experiencing. Progress can be noted in any number of ways around family functioning, depending upon the particular case. For example, improvement can be reflected in a decreased need for scheduling family sessions, an increased willingness to schedule family sessions, decreased reports of familial discord, improved communication and emotional regulation in the presence of family members, and increased or improved interaction with family members in the group setting.
For example, one adolescent girl entered the multifamily skills training group with both her mother and her stepfather. Whereas she had a fairly stable relationship with her mother, she had an acrimonious relationship with her stepfather—as indicated by sarcastic exchanges in group, her storming out of family sessions in tears, his critical remarks about her in both group and family sessions, and his inconsistent attendance in the group. According to the adolescent’s and her mother’s reports, the stepfather’s and teen’s behavior at home toward each other was highly conflictual, characterized by limited contact and frequent angry flare-ups when interaction was attempted by either party. By the end of treatment, though their interactions were far from perfect, these had improved substantially. Both parties had reduced the frequency of sarcastic exchanges and were attempting to be more interpersonally effective (expressing feelings and desires more directly and gently). The teen remained for a whole family session, even when things got heated. The stepfather was no longer making frequent critical comments and had increased the frequency of validating his stepdaughter. Although he still did not attend every scheduled family session because of stated work conflicts (much to his stepdaughter’s dismay), he did attend most of them, and on their “graduation night” he shared observations about his stepdaughter that were glowing in his praise of her improvement and what she meant to him. (This also resulted in her tears, but with no urge to storm out of the room!) Clear improvement was mirrored in other aspects of this teen’s functioning as well.
Note that in cases in which parents have themselves been engaging in highly maladaptive behaviors—such as abusing alcohol, behaving aggressively toward their children, having too severe or too liberal limits, reinforcing dysfunctional behaviors, or having in the past sexually abused their children—mending relations might be complicated or nearly impossible, or at a minimum might take additional family sessions to accomplish. Progress might be marked by an adolescent’s beginning to confront a situation he or she had previously avoided (e.g., by assertively expressing the impact of the parents’ behavior patterns), by a family’s agreeing to attend an intensive and perhaps specialized family-focused treatment following Stage 1, or by a parent’s admission of and willingness to begin addressing the problematic behaviors. Conversely, progress might be marked by an adolescent’s work toward radically accepting the parent’s behaviors (or even protectively distancing him- or herself from a dysfunctional situation), while focusing on adaptive steps toward self-care, such as building other sources of social support and taking steps to achieve long-term goals.
Problems with specific clients—such as therapists’ difficulty in regulating their own emotions during sessions, difficulty in implementing treatment effectively, or difficulty in the therapeutic relationship—often dominate therapist consultation team discussions. Certain therapists may need more attention than others because of their clients’ difficulties, and the team quickly learns which therapists need support regarding cases with which they are struggling. Additional signs of progress can be found in the team’s lessening focus on a particular therapist. That is, when team attention shifts away from such a therapist, when his or her discussion takes less time, or when the therapist becomes more balanced and emotionally regulated in discussing problems in relation to the client or family, progress has probably occurred.
A note of caution, however, involves the fact that a shift away from discussing a problematic situation can indicate not improvement, but possibly avoidance or hopelessness on the part of the therapist or team. Thus, if team members notice the absence on the agenda of a therapist whose case has been the focus of much recent discussion, the team should check in with the therapist, follow up on the case, and clarify the reason for the lack of discussion (and reconsider placing the therapist on the agenda, if needed). It must be remembered that burnout—of therapist, of team, of group leaders, and/or of clinic staff—is a common scenario in work with suicidal multiproblem adolescents. Thus, if team discussion has drifted away from a therapist because of burnout and not because of improvement, the burnout must be addressed. The team can work with the therapist to assess the source of the burnout and attempt to alleviate it with such strategies as suggesting new approaches, identifying where the therapist has become unbalanced, enhancing empathy for the client, generating hope about the case, reviewing the biosocial theory, revisiting commitment strategies, or (in more extreme cases) suggesting that the therapist take a vacation from the therapy. In essence, the therapist’s skills in treating the client must be enhanced, and improvements in a therapist’s and a client’s skills typically go together.
How does the therapist know whether the treatment is working or not working? Essentially, if over time a client is attending, complying with the various demands of treatment, participating actively in treatment, and making progress on identified target behaviors, then treatment is having its intended impact. However, some client–therapist dyads seem to get “stuck,” and the therapy stops progressing or does not seem effective.
If progress is not occurring, the therapist’s implementation of the treatment will need additional examination by the therapist consultation team (or through the therapist’s individual supervision, if applicable). Some change in approach is likely to be warranted. Is there some lack of “buy-in” to the treatment on the therapist’s part? Has the therapist been properly trained, or could he or she benefit from more training? The team (and, if relevant, the individual supervisor) must troubleshoot with the therapist to discover what is not working. The problem may lie in the application of behavior and solution analyses. For example, the therapist may not be devoting enough time to identifying factors that interfere with engaging in solutions and determining how to overcome them. Often the problem will lie in the therapist’s losing balance in the treatment, such as placing too much emphasis on validation or on problem solving; being too flexible or too rigid; or applying too great a degree of warm, nurturing communication or irreverent communication. Sometimes the problem will lie in the fact that the client has shaped the therapist into doing ineffective therapy, such as not adhering to the DBT session format (e.g., behavioral analysis of behavioral targets according to the target hierarchy). At times, the therapist will have lost the ability to remain nonjudgmental and empathic to the client; at other times, the therapist will have lost this ability with regard to clients’ family members. Working with adolescents requires DBT therapists to have an equal capacity for validation, problem solving, and reestablishment of commitment with the teens’ family members—especially when the teens are reliant on their family members to get them to and from the office.
With a highly suicidal client in particular, the therapist’s own emotional responses to the threat of an impending suicide (e.g., fear or anger) may immobilize the therapist or lead to overly protective or punitive responses. It can take all of a team’s combined skills to ferret out what the actual problem is. For example, a group leader in the University of Washington clinic reported weekly that clients were angry and hostile toward him. Several threatened to quit; suicide threats in group sessions were not uncommon; and the therapist was so miserable that he was getting burned out and wanted to quit himself. He had felt too ashamed to bring the topic up in team, and it was not until two group members quit that the topic was discussed by the team. The most frequent complaint from clients was that the therapist was dismissive and nonvalidating; the therapist reported that he was doing his best to validate. When the team members got the therapist to role-play with them how he responded to group clients, it was immediately apparent that he indeed did sound dismissive. Further investigation revealed that when he was attacked, the therapist got quite anxious—and when he was anxious, not only did his cognitive processing decrease, but his responses sounded dismissive instead of validating. In addition, his shame that his therapy was not as good as that of other team members was so great that he could not discuss the topic in team meetings without great difficulty. The treatment, organized by the team, was for the therapist to record his group sessions and then listen to them daily until both his shame and his anxiety went down. He was instructed to employ opposite action when discussing his group in team meetings: keeping his shoulders back, making his voice confident, and maintaining good eye contact, while telling the team all the details without apologies or self-judgmental statements. For several weeks, part of each team meeting was devoted to role-playing with the therapist situations that arose in his group. His homework assignments were to notice when his anxiety started increasing while he was leading his group, and to share with his group the advice he was receiving in team meetings. The conclusion of this was that his group members became allies with him in changing his behavior; his shame disappeared; and he became more skillful at managing his anxiety in his groups.
The therapist and team should consider also whether it is possible for the therapist to be missing signs of progress—assuming that treatment is not working, when in fact change is occurring. For example, consider the case mentioned earlier of the therapist’s spending the whole therapy on the diary card. This client may have appeared “stuck,” but her therapy-interfering behaviors were a microcosm of the controlling variables for most of her problem behaviors, and eventually change in these targets occurred.
Whatever the reason for therapy’s getting off track, the therapist is advised to access his or her own “wise mind” to reflect on the situation, and to bring the situation to the therapist consultation team for discussion. The team’s purpose is to “treat” the therapist; in making use of this critical component of DBT, the therapist can become reenergized and recommitted, and ideally will get unstuck.
When a therapist is working with a suicidal population, it is likely at some point that the therapist will experience a client’s suicide. When that client is an adolescent, this experience can be especially devastating. Moreover, a therapist who has been working with the teen’s family faces not only the loss of the client, but also the grief and despair of the parents. Responding to an adolescent suicide is thus a delicate and complicated matter.
When the individual therapist or other primary therapist learns of an adolescent client’s suicide through someone other than a family member, the therapist should call the family promptly and should offer condolences, as kindly and empathically as possible. The therapist should also go to the funeral, demonstrating his or her connection to the client and family. In all family interactions, the therapist should monitor any tendency to blame either the family or him- or herself. Both of these are within the realm of normal reactions, but neither should be communicated to the family. The family may desire ongoing support and treatment from the same or from a different therapist. Regardless, the therapist should make ample use of the consultation team concerning the inevitable range of strong emotions that will occur, the potential impact on work with other clients, the decision regarding whether or not (and, if so, how) to proceed with the family, and ways to handle the incident with the skills training group.
In general, if the client who committed suicide is also in a skills training group, we recommend that the other adolescent members’ primary therapists (ordinarily their individual therapists) call their clients prior to the next skills group meeting, inform them of the group member’s suicide, and handle whatever interventions are needed for each client (e.g., validation, distress tolerance skills, etc.). Then group leaders should process the suicide in the next couple of group sessions. Allowing significant time to attend to the suicide in the skills group indicates sensitivity to group members’ inevitably strong reactions, demonstrates the caring and concern of skills trainers, and allows both skills trainers and group members to process powerful emotions that would surely interfere with the normally scheduled skills training. Skills trainers can help facilitate the processing of the suicide in a number of ways: by answering questions, to the extent possible (which must be balanced with respecting the deceased client’s confidentiality and the family’s right to privacy); by allowing members to make comments and share their reactions; by normalizing the reactions shared; by eliciting skillful ways of coping with painful reactions; and/or by inviting members to share thoughts or memories of the deceased client. A particularly helpful process is to invite group members to plan a tribute session or memorial ceremony for the deceased client. The skills trainers might also want to encourage close contact with individual therapists, family members, or other supportive figures during this difficult time. Adolescents might experience an increase in suicidal ideation; family members in the group might need additional contact as well, because they feel grief for the other parents’ loss and fear that their own children are at heightened risk. In group, it is important that after about two sessions, the skills trainers gently turn the focus back to the didactic curriculum. This acknowledges that clients in treatment still need to enhance their capabilities; it demonstrates continuity and consistency, which group members may experience as reassuring; and it models a balance between grieving and moving forward.
In any evidence-based treatment program, it is critical to include at least some evidence-based assessment instruments. What measures to include depend primarily on the focus of the treatment program or the goals of specific clients. In our Montefiore DBT program for adolescents, we assess progress through a series of formal measures; these include a number of standard measures that target suicidality, features of BPD, and related behavioral patterns. These measures and the time frames for administering them within our outpatient program are described in detail in Chapter 6. We will not describe them again here, except to mention that filling out measures at the end of treatment or treatment modules may, for adolescents, be reminiscent of school exams. They may feel they have to mark down the “right answer,” and thus their responses may be especially subject to demand characteristics. It is thus important to orient them to these assessments by stressing that there are no right or wrong answers, and that their honest answers to the items are the best responses.
We also suggest using objective ratings of several relevant factors to determine improvement as a result of treatment. These include the number (and days) of psychiatric hospitalizations and emergency room visits during treatment; the number of suicide attempts during treatment, defined as self-injurious behaviors with the intent to die, and based on clients’ self-reports during the course of treatment; the number of NSIB incidents, also based on self-reports during the course of treatment; and treatment completion, indicated as a dichotomous rating of “yes” or “no” based on whether clients complete the agreed-upon treatment program.
In sum, the suggested assessment battery we describe in Chapter 6 is intended to serve as a guideline to assemble an outcome battery in a particular treatment setting to help determine whether the adolescent clients have improved on standardized assessment tools.
Since documented rates of relapse and recurrence among depressed adolescents are high, clinical researchers have recommended either booster or continuation treatment to address this problem (Birmaher et al., 2000). Thus, in work with suicidal adolescents, we recommend the use of a second group phase of treatment. It not only makes clinical sense to have a continuation phase in treating multiproblem suicidal adolescents, most of whom also have mood disorders; but it can also help them make the transition out of therapy. For example, our graduate group helps wean adolescents from first-phase group skills training by reducing the role of group leaders (i.e., greater use of peer coaching and problem solving, and of adolescents themselves as teachers of skills). This section reviews the rationale for a graduate group for adolescents, and describes the particular model employed at Montefiore Medical Center. This is one of many possible continuation-phase models. Also note that participation in a graduate group can occur concomitantly with standard DBT Stage 2 individual therapy focused on emotionally processing the past.
In an advanced skills or graduate skills group, the primary goals are (1) to prevent relapse by reinforcing the progress made in the previous skills training group; (2) to help clients generalize their behavioral skills; and (3) to help clients increase behaviors instrumental to a positive quality of life, while decreasing behaviors interfering with a positive quality of life. To achieve these primary goals, the group leaders encourage the adolescents to “consult” with, validate, and reinforce one another to manage their current life problems more effectively, with less emphasis on the leaders. Ideally, the clients will continue to rely on one another after the group ends, having become less reliant on the adult therapists. Group therapy is an especially powerful therapeutic tool with this age group, since peer relationships promote the development of social skills and identity formation (Brown, 1990). Positive peer relations can also foster improved self-esteem, provide buffers from stress, and (in the case of academically successful peers) improve adolescents’ view of school (cf., Berk, 2004; Eccles et al., 1993). Moreover, the transition from the first phase of treatment to the second-phase graduate group is characterized by placing increased responsibility on group members in terms of participating without parents, taking active teaching and consulting roles in group, and solving problems with peers. These changes mirror the adolescent developmental trajectory toward separation, individuation, greater self-sufficiency, and greater importance of peers.
The Montefiore graduate group is an optional program continuation consisting of adolescent first-phase graduates and two therapists. We find that more than half of these graduates elect to participate in the graduate group. Individual therapy and the multifamily skills training groups are discontinued at this point; less intensive contact is needed, since the eligible clients are no longer in a state of severe behavioral dyscontrol. On a case-by-case basis, however, we will at times provide a more intensive second phase of treatment, with some continued individual therapy and family sessions supplementing the graduate group.
The graduate group is less time- and therapist-intensive than first-phase group skills training. The graduate group consists of a 2-hour group session once per week for 16 weeks, with the opportunity to recontract for an additional 16 weeks if an adolescent is able to identify clear treatment goals. Some teens recontract several times, resulting in their graduate group participation for more than 1 year. Telephone consultation is still used as needed in this modality, as are individual or family sessions led by one of the group therapists. The two therapists are expected to participate in the weekly DBT therapist consultation/supervision meeting for the same reasons described in Chapter 4. Table 11.1 summarizes the treatment modes used in this graduate group. Typically, four to five teens participate in the graduate group at one time; more than five teens in one group would potentially preclude some of the group members from getting enough attention paid to their respective problems.
In the Montefiore program, we have developed a target hierarchy for adolescents participating in the graduate group. In contrast to the first-phase skills training groups, where little attention is paid to in-session interpersonal process issues, the graduate group utilizes behaviors that occur outside as well as within the group sessions as a means to change. Hence the major targets address in-session behaviors that are inevitably linked to maladaptive behaviors outside of treatment.
TABLE 11.1. Graduate Group Modes of Treatment
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The hierarchy of treatment targets for a graduate group is outlined in Table 11.2. Decreasing life-threatening behaviors is not included as a target here, because it is assumed that once clients are in a graduate group, life-threatening behaviors have been eliminated. (If such a behavior should recur with increasing frequency, the therapist should address it as a top priority, but should also seriously consider whether the client needs to be back in more intensive treatment addressing the standard Stage 1 targets.) It is also assumed that once clients are in a graduate group, therapy-interfering behaviors will be eliminated or nearly eliminated, but if they show up, they are addressed as a high priority. Decreasing therapy-interfering behaviors (e.g., not coming to group, coming late to sessions, not doing homework, not taking medications, verbally attacking or being disrespectful toward other clients or group leaders) therefore becomes the primary concern. Targeting these behaviors for elimination allows the therapists and other group members to address the second most important target, which is strengthening interpersonal effectiveness skills. Inevitably, conflicts and problems arise in group members’ relationships; the group is seen as a microcosm of their lives in which to practice the use of these skills, while receiving constructive feedback from peers and staff. The third target is increasing behaviors that are instrumental to a positive quality of life, while decreasing behaviors that interfere with a positive quality of life. These behaviors include addressing the secondary treatment targets that affect life quality and derive from the behavioral patterns common among clients with BPD or borderline features, as identified by Linehan (1993a) and Rathus and Miller (2000) (see Chapter 5).
An example of addressing the secondary treatment targets involved Jennifer, a 17-year-old Asian female, who grew up in an extremely invalidating environment. Her father had left the family when she was 2, and when she attempted to reconnect with him at the age of 15, he stated that he did not want to be around her because she had so many problems. Her mother repeatedly invalidated her. The first phase of treatment helped reduce some of the day-to-day invalidation, with the help of the mother’s participation in the multifamily skills training group and family sessions, but Jennifer was still prone to invalidate herself on a regular basis. Self-invalidation became an explicit target behavior addressed in the graduate group. Thus any time Jennifer invalidated herself, one of the group leaders or a peer would gently say, “That sounds like self-invalidation … can you describe how you feel without invalidating yourself?” In the beginning, this was difficult for Jennifer to hear and even more difficult to correct. However, as time went by, Jennifer became better able to catch herself in the act of self-invalidation and to restate her thoughts and feelings without self-invalidation and without prompting.
Another example of addressing secondary targets in the graduate group pertained to Latoya, a 14-year-old African American female. Latoya had a history of severe trauma and a long psychiatric history, including multiple hospitalizations, multiple suicide attempts, self-cutting, PTSD, depression, panic disorder with agoraphobia, drug and alcohol abuse (presently in remission), and dissociation. She was a likeable young woman with a tragic past. Her active passivity in sessions was evidenced by her lack of response to obvious problem-solving situations. She would often present a problem, and when asked what she tried or could have tried to address the problem, she would passively reply, “I don’t know.” The group leaders experienced tremendous sympathy and empathy for her, which resulted in their becoming overly active in trying to solve her problems for her. It took several months before the coleaders recognized that they were inadvertently reinforcing her passivity by solving problems for her. While active passivity became one of her target behaviors (as discussed between therapists), the phrase used to describe this target behavior to her was “a need to increase active problem solving for yourself.” She recognized her difficulty in actively solving her own problems. She was oriented to the treatment plan for her, which entailed the coleaders’ and peers’ “sitting on their hands” until Latoya produced at least one or two possible solutions to her own problems, before chiming in with other feedback.
TABLE 11.2. Target Hierarchy for a Graduate Group
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Montefiore graduate group sessions follow the basic structure outlined in Table 11.3. The following discussion describes what happens within each segment of the session.
Each meeting starts with a 10-minute mindfulness practice exercise. A different adolescent or group therapist leads the exercise each week, based on a prearranged rotating schedule. Adolescents who lead these exercises reap several benefits. First, they have an opportunity to be creative in the development of their own mindfulness exercises. Second, they practice taking on the role of “leader,” which can enhance their self-esteem and sense of mastery. Third, the more they teach, the more likely they are to employ their mindfulness skills on command in their lives outside the group.
Since they are no longer in the first phase of treatment, graduate group members are not required to complete or return diary cards, However, we believe that it is clinically imperative to continue to assess certain target problems and behaviors in the group each week. Therefore, a semistructured assessment is built into the group’s agenda; we call this the “virtual diary card.” In this way, therapists learn how each individual has been functioning over the past 7 days, what needs to be addressed during the group session, and what information will be documented in each client’s progress note/medical record.
TABLE 11.3. Format of Montefiore Graduate Group (2 Hours)
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The virtual diary card review begins when one of the group leaders asks each group member to rate the following behaviors quickly on a scale of 0–5 (except as noted), based on the previous week: depression, anger, anxiety, self-harm thoughts, self-harm actions (yes–no), suicidal thoughts, and suicidal actions (yes–no). Each client is also asked to rate current self-harm thoughts/suicidal thoughts (i.e., today); to list any positive emotions and rate their intensity; to list which specific skills were used (referring to the diary card list) and give an example of applying one skill; to indicate compliance with pharmacotherapy (yes–no); and to review homework. The virtual diary card is tailored to the individual needs of the client, just as a standard diary card is. Hence some clients are asked to rate urges to use drugs/alcohol, and then to report the frequency and intensity of actual substance use behavior. Similarly, for clients with eating disorders, restriction, bingeing, and purging urges and behaviors are assessed. A group leader writes down their responses.
These ratings take approximately 5 minutes per person. If an adolescent endorses NSIB or suicidal action, or changes in ideation in either domain, time is spent discussing this later during that client’s allotted consultation problem-solving portion of the session. Regardless of the adolescent’s preference, the group leader will conduct a behavioral analysis of these target behaviors and will engage the adolescent and the other group members in the solution analysis. Chronic self-harm urges or suicidal ideation does not necessarily require the same intensity of analysis as NSIB or suicidal action, since many of our clients retain their thoughts about such actions long after the actions are extinguished. Clinical judgment determines whether a behavioral analysis is required. Senior group members are sometimes asked to help “conduct” the behavioral analysis of a peer by standing at the blackboard, asking questions, and writing down the responses. Ultimately, the individual client who engaged in the behavior is asked to conduct his or her own behavioral analysis in front of the group.
Some research suggests that a detailed discussion of self-injurious behavior in a group setting may serve as a form of contagion (Velting & Gould, 1997). The dilemma is that when a group becomes the primary modality of treatment, it also becomes the only context in which to discuss any target behaviors, including life-threatening behaviors. Our synthesis is that we ask clients not to provide any specific details about the self-harm itself. However, we do ask them to identify the vulnerability factors, the precipitant, the key links in the chain preceding the target behavior, and the consequences. Lavish reinforcement is provided to the identified client and peers who help identify effective solutions in the solution analysis. The skillful graduate group therapist has to be capable of conducting a behavioral analysis and engaging peers in the solution analysis, while not reinforcing pathological behavior or fostering contagion.
Each week, the group members are asked which skill they would like to review. The group therapists try to obtain a consensus and then ask which adolescent would be willing to lead the review. If no one volunteers, the group therapists either teach the skill themselves or ask one of the more senior members whether he or she would be willing to teach the skill standing at the blackboard. Often this adolescent agrees, with some mild encouragement and reassurance that the group therapists will provide help if necessary. Typically, the adolescent who requests the skill is asked to give a real-life example to bring the “lesson” to life.
For example, one adolescent named Shanti, a 15-year-old Hispanic female, asked for a review of the pros and cons skill. Michelle agreed to lead the discussion and went to the blackboard, where she gave the rationale for using pros and cons. She asked Shanti for an example in which she might need to use the skill. Shanti, who had recently been living in foster care, was now reunited with her biological mother. Although both parties many challenges faced during this reunification period, Shanti stated that a major stressor for her right now was her mother’s “nagging behavior.” The client stated that she was unaccustomed to having anyone “parenting” her; thus, while she understood that her mother was trying to do her job, it was “too much, too soon.…Did you do this? Did you do that? Can you do this? Can you do that?” The client continued to describe her efforts to tolerate her distress, since she did not want to hurt her mother’s feelings, but recognized her urges to “tell Mom to back off” if her mother did not stop her “repeated requests” (newly described term without judgment). The group helped her review the pros and cons of tolerating her distress versus the pros and cons of not tolerating her distress. In addition, the group helped Shanti identify which of those pros and cons were short-term and which were long-term. Shanti was easily able to identify that it made sense to use her GIVE and DEAR MAN skills. Shanti role-played with a DBT group leader how she was going to validate both her mother’s and her own perspectives, while also directly asking her mother to make one clear request of her at a time without repeating herself. Shanti received significant praise from the group, and Michelle, the adolescent who had led the “lesson,” received a round of applause from her peers. Shanti’s homework assignment for the upcoming week was to follow up with her mother using her DEAR MAN and GIVE skills.
The group takes a 10-minute snack break after the skill review.
The consultation and problem-solving stage of the group is the most important and the longest component of the group (70 minutes). A primary function of the graduate group is to provide consultation to adolescents regarding the management of their current life problems. To achieve this function, the group members must be able to employ their interpersonal effectiveness skills and provide heavy doses of validation and positive reinforcement to one another.
Group leaders divide this time by the number of members to determine how much time each member is allowed to receive consultation. Since a preferable number of teens per group is four or five, each member is typically allowed approximately 15 minutes to discuss his or her problems. Naturally, exceptions are made to the time limit. For example, when one girl discovered she was pregnant and wanted to make a decision regarding abortion, some of her peers willingly forfeited their time to lengthen the discussion. However, in some cases it is important to balance the clinical necessity of discussing certain issues further with the potential for inadvertently reinforcing certain maladaptive behaviors and inadvertently extinguishing adaptive behaviors by ignoring members not in crisis. Group leaders make an effort to reinforce adolescents’ progress, positive life events, and effective use of behavioral skills by spending sufficient time discussing these “positive events” as well as the problematic ones.
Adolescents are reminded to frame their discussions in such a way as to encourage feedback. Moreover, those who provide feedback are encouraged to use and reference DBT skills whenever possible, both to reinforce the learning process and to ensure that clients are sharing the same language. Unfortunately, at first, many teenagers exhibit profound difficulty expressing validating comments and behavior. Given their histories of pervasive invalidation, adolescents tend either to remain quiet and expressionless or to bring the conversation back to their own experience without making the validating link by saying, “I know how you must feel.…I have been through something similar.” Instead, they may inadvertently invalidate their peer by “stealing” the problem and not returning to the first adolescent’s original problem. Group therapists must highlight this inadvertent maneuver and teach, via role plays, how to validate peers more effectively.
In one case, Beth, a 17-year-old white female, described her anxiety and anger toward her boyfriend for looking at and flirting with other girls in front of her. A male peer responded with bravado, “What’s the big deal? Just ’cause you’re looking at the menu doesn’t mean you have to order.” The group stopped in surprise, and another female exclaimed, “Peter, that’s so messed up. You totally invalidated Beth. I think Beth has every reason to be upset. I’d be upset if my boyfriend was doing that!” Peter replied, “I didn’t mean to invalidate her.…I was actually trying to validate her by saying this is what guys do these days and not to take it personally.” The group leader asked Beth how she had experienced Peter’s comment. Beth reported that it felt invalidating; however, Peter’s explanation made her feel a little less hurt, since he was trying to help. The leader asked Peter whether he could retry validating Beth, using a slightly different approach, but he expressed uncertainty about what to do. When indicated, a brief didactic presentation may be employed. In this case, the group was referred to the validation skills, which include listening skills and specific validation techniques. The group reviewed key ingredients missing from Peter’s effort to validate Beth. The leader then asked Peter to formulate another validating statement, given Beth’s feelings. The group gave Peter feedback as he tweaked his statement further. Finally, Peter was instructed to say it to Beth directly, with appropriate tone and eye contact. Although such a statement often feels artificial since it has been constructed by the group, it is important for an adolescents to say it in as natural a way as possible, without avoiding it or stating it sarcastically.
In addition to validation and reinforcement, teens consult to one another in a variety of ways, such as how to solve certain current problems. Peers might suggest the use of new or different skills, suggest alternative ways of thinking about a situation, or help clients work toward radically accepting certain “unacceptable” events in their lives. When they are senior enough in skills application, teens can volunteer to serve informally as peer coaches outside of the group. The group phone list is regularly updated, and teens are permitted to call each other for coaching outside of sessions, under two conditions: (1) Distressed teens are required to call the group therapists after they speak with a peer if they require more coaching; and (2) teens are not permitted to discuss prior self-harm behaviors with one another outside of therapy sessions.
One teen reported in a group session that she had called another group member the night before to discuss a problem. The problem involved a conflict this 15-year-old girl was having with her mother about her poor school performance. She was feeling extremely invalidated by her mother’s criticism that “You clearly aren’t trying in school, and that if you cared at all about me, you’d try harder so that it wouldn’t give me so much worry.” The teen explained to her peer on the phone that she was actually trying as hard as she could, but that because of her depression, she had trouble concentrating and consequently was performing poorly at school. The distressed teen reported with appreciation to the group how the peer coach first validated her feelings, then encouraged the teen not to judge herself as her mother was doing. Rather, she helped the teen validate herself. Finally, the peer coach suggested that the teen remind her mother the next day that (1) the problem was not one of motivation, but rather one of her depression symptoms, which were presently interfering in her academic achievement; and (2) the teen too felt bad about her poor grades. The distressed teen expressed enormous gratitude in group to the peer coach for making herself available, for offering her validation, and for suggesting specific strategies for what to say to her mother the following day. The peer coach responded, “It’s much easier when it’s not your own mother. I don’t get in emotion mind when it’s your mother.” The group leader reminded the peer coach that she had still offered support and helpful concrete advice to her peer, and suggested that the next appropriate response to give would be: “You’re welcome…any time.” She followed through with the recommendation, and the group proceeded.
The last activity of each graduate group session is a ritual called “closing observations and commitment.” The group is given the following instructions: “Assume the mindfulness position, and after the sound of the bell, group members in any order may share one nonjudgmental observation about today’s group. After that, please state what you commit to work on this week.” One of the group leaders always goes last, and often includes as part of his or her closing observation a comment about any members not present and the wish for them to return next week.
The function of the closing observation is to help the clients (1) practice mindfulness skills, including observing, describing, not judging, and staying focused; (2) return to wise mind, since they may have been in emotion mind earlier in the group; and (3) practice self-and other-validation skills as well as reinforcement skills. The observations may range from “I am glad I came today…the group helped me feel better about myself,” to “I observed that Susan worked hard today talking about her relationship problems with her mother,” to “I am feeling very sad.” Typically and fortunately, the closing observations help provide closure to an often emotionally intense group session.
The commitments often include individual assignments given during the group. Examples of commitments include “I am going to work on radically accepting the fact that my classmates are unable to handle the news that I am gay,” “I am going to submit my college applications by the next group,” and “I am going to commit to using my DEAR MAN skills with my friend who keeps wanting to discuss her self-cutting with me, since it really upsets me.”
Two factors determine when treatment should be terminated: a client’s progress and the constraints of the treatment setting. In settings in which research protocols are being implemented, or in clinic or hospital settings with standardized treatment programs and strict time frames, the treatment structure determines the timing of an adolescent’s treatment completion. However, even in such settings, exceptions must be made when severe behavioral instability persists. This may involve, for example, inviting the adolescent to repeat a portion of or an entire treatment program. At a minimum, clients entering therapy with high-priority Stage 1 target behaviors (i.e., with out-of-control behaviors that are life-threatening or severely compromise functioning) should ordinarily remain in treatment until adequate behavioral control is achieved. Once behavioral control is achieved, clients may terminate therapy altogether, take a break from therapy for some time period, or end one programmatic treatment and enter another program. When the latter is the case, the program transition may require terminating treatment with one or more therapists while still remaining in a coordinated DBT program. The exception to this rule of keeping clients in treatment throughout Stage 1 is when treatment is carried out as part of a research protocol where one of the outcomes is clients’ functioning at the end of a specified time period. In these cases, particularly when suicidal behavior is not under control by the end of the protocol, it is essential that the program therapist organize a referral to continuing treatment.
In private practice settings, inpatient settings, or clinic or hospital settings with more flexible time frames, treatment length can be more of a general guideline than a policy. Generally, in these settings, an expected treatment length is negotiated at the start of treatment (e.g., 16 weeks, 24 weeks, 1 year); then, as the termination date approaches, therapy is reviewed to decide wither treatment should end at the agreed-upon time or a new agreement should be made. It is ordinarily important, however, to set specific time points for “go-no-go” reviews to prevent therapy from drifting or becoming a supportive relationship with little or no therapeutic change demanded or expected. Holding open rather than closed skills training groups facilitates the flexibility of a client’s participation in treatment; the client can remain for additional modules in the skills training modality, rather than having to begin with a whole new cohort of clients.
In work with an adolescent, transitions in the client’s life may result in termination’s being determined by timing rather than clinical judgment. For example, once the school year ends, many adolescents may accept summer employment that interferes with the therapy schedule. They may also go away to summer camp, depart for their countries of origin, or leave for college. Still others will terminate abruptly because their parents decide to cease the therapy. When such abrupt terminations occur, the therapist can work to ease the transition in a number of ways. First, when such terminations are anticipated (e.g., leaving for college), planning in advance can occur, and referrals can be made if needed. Second, in some cases phone contact can be maintained for a specified period of time (and perhaps faded) to ease the transition away from therapy. Third, some adolescents and parents will at least be willing to arrange a termination session to handle issues of referrals, future plans, or the possibility of returning to the therapy at a future date.
The handling of termination depends on the setting and the program structure. For inpatient, residential, institutional, or day treatment programs, termination is normally planned with arrangements made for follow-up care, typically in a less restrictive and time-intensive environment. In outpatient settings, termination may be delayed; instead, a transition may involve moving to a less structured phase of DBT (e.g., an exposure-focused treatment or some type of client graduate group), a different form of therapy, a gradual tapering process, or less frequent maintenance or “check-in” sessions.
If the treatment program is divided into phases, a transition takes place to the next phase, and termination is addressed at the end. Yet the end of the first phase is significant and marks a change in the format of the therapy. The intensive contact and format of individual therapy and the skills-acquisition-based multifamily skills group are often completed, and give way to a less time-intensive form of treatment (either individual therapy alone or a client graduate group). This phase shift makes for a “weaning” of sorts, with the adolescent taking a more active and independent role in his or her treatment. To determine whether the adolescent can move beyond the structured skills training, the primary therapist and the skills trainers should ensure that the adolescent demonstrates sufficient knowledge and practice of skills. This can be done by noting whether the client has shown understanding and application of skills in group, as well as whether the teen is putting those skills into practice by no longer being in Stage 1. In at least one setting we know of in Seattle, skills trainers require clients to pass a test to get into graduate groups; in this way, clients must demonstrate that they have learned the skills.
The first phase of treatment requires getting severe behaviors under control—suicidal behaviors and other severely maladaptive behaviors, such as not attending school, homelessness, severe substance abuse, or high-risk criminal behavior. In other words, clients must engage in normative behaviors. They must also be able to function in the skills training group. As completion of the agreed-upon length of the first phase of treatment nears, the individual therapist prepares the adolescent to complete this phase and move on to the next. Although the session format continues (i.e., review of diary card and behavioral analysis), the therapist will nevertheless allow some time for addressing the transition or termination. This involves feedback about progress, strengths, skills acquired, and areas that still need to be the focus of attention. This assumes, of course, that session time at this point is available for such discussion and not consumed by behavioral analyses of higher-order treatment targets. For many suicidal, emotionally dysregulated adolescents we see, the Stage 1 overarching targets of stability and behavioral control can be attained within 16 weeks (e.g., see Rathus & Miller, 2002). However, if these overarching targets remain (as they do in a subset of adolescents with more chronic and severe problems), the therapist should be discussing a continuation of addressing Stage 1 targets (which often corresponds to the first phase of treatment) with the client, rather than planning termination or a move to a second phase of treatment. Even when these target behaviors have substantially subsided, the therapist can point out areas that still need clinical attention. These areas should be actively addressed by the adolescent in a continuation phase of treatment, whether this involves individual therapy or some type of graduate group. In addition to feedback, the therapist anticipates with the adolescent potential areas that could cause setbacks or crises, and troubleshoots possible skillful responses. Often there is some exacerbation of old behaviors when termination nears. Stylistically, it is important that the therapist assess and validate the client’s concerns about termination, while also engaging in problem solving and cheerleading.
When adolescents are engaged in a shorter-term outpatient treatment format, their therapists strongly encourages them to repeat a cycle of therapy when there is a need for continued work on Stage 1 targets. When clients have demonstrated control over the severe types of behavior targeted in Stage 1, they can move on to another phase of treatment. Typically, they are told about continuation phases available to them at the outset of treatment during orientation, but a therapist discusses continuation phases in more detail as a transition approaches, in terms of how they might benefit a particular adolescent. If clients have made substantial progress toward their Stage 1 goals (i.e., decreasing life-threatening behaviors and other severe forms of behavioral instability), they may wonder about the rationale for continuing in another form or mode of therapy. The therapist reiterates the rationales for the next phase of treatment, depending on what this phase is to consist of (e.g., to work on PTSD, to address problems in a less structured individual therapy format, to continue in a group setting to provide a forum for generalizing and strengthening the gains made, to prevent relapse, and/or to offer continued therapeutic contact should additional challenges arise). When a therapist believes that an adolescent has much to gain from continuing in treatment, orientation and commitment strategies can be applied at this point, as discussed in Chapter 7. However, many adolescents themselves desire additional treatment and are eager to continue in some format, especially when this involves continued contact with the program.
In preparing the adolescent for moving on to the next phase of treatment, the therapist might communicate a sentiment such as the following:
“I know it’s going to take a little time to get to know and trust your new therapists [e.g., graduate group coleaders] and peers. Yet I expect you will learn to trust, like, respect, and get help from them. And, at the same time, I will always be your former therapist; hence, I would love to hear how your life proceeds—for example, when you graduate from high school, what college you choose to attend, and so forth. So if you feel like dropping me a note or postcard from time to time, send it to the clinic [or give it to the graduate group leaders and ask them to pass it along].”
Ideally, clients should continue skills training until they have mastered enough skills to be no longer engaging in life-threatening or therapist-interfering behaviors. When a multifamily skills group is being conducted in an open format with rotating entry points, some adolescents and their family members will graduate at the end of each module, as described in Chapter 10. During the last session of each module, the group leaders can conduct skills training according to the regular agenda for approximately three-quarters of the session, but devote the last quarter to acknowledging those who are graduating. This acknowledgment might involve presenting each graduating adolescent and family member with an attractive certificate of completion (e.g., rolled in ribbon like a diploma); encouraging each other group member (teen and parent) to make observations and provide feedback about the graduating group members’ progress, as well as feelings about their leaving; and encouraging the graduates to offer feedback to each remaining group member (and leader). This type of exercise invariably proves emotional, moving, educational, and reinforcing of the good work clients have done. We are always impressed at the insights and perceptive observations about graduating clients offered by fellow group members. Perhaps most moving is the feedback the graduates provide to their own family members. Lastly, the group leaders might provide each teen or family with a small symbolic gift, to help them to remember or practice skills. For example, we have recently been giving departing members a CD called The Wise Movement (Behavioral Tech, 2004), a review of DBT skills put to music. Teens in particular respond well to such ceremonies and symbols of completion, similar to what occurs with school transitions.
As individuals who are also taking responsibility for the treatment (since DBT is the treatment of a community of patients by a community of therapists), it is the responsibility of the team members to help each therapist both stay within the DBT treatment parameters on the one hand, and respond flexibly to new problems on the other hand. With respect to termination, the team has three major tasks. First, the team assists the therapist in determining when a client’s treatment should be terminated. Although in a time-limited treatment program this may not be a major issue, it can become an important issue to think through when a client does not appear to be improving sufficiently, even though the end of the agreed-upon time for therapy is approaching. In our experience, both therapists and clients often want to extend therapy when an extension is not necessarily needed. This ordinarily occurs in cases where a therapist, a client, or both underestimate the client’s abilities to cope and/or overestimate the problems the client is facing.
A second major role of the DBT team—somewhat the reverse of the first task—is to “re-moralize” any therapist who is not only getting burned out with a particular client, but also starting to believe that the client simply isn’t ready to change. In these cases, particularly with an adolescent who intermittently threatens to quit therapy prematurely, it is easy for the therapist to pull back and do little to reengage the client in the therapeutic process. In working with clients addicted to heroin in particular, therapists at our University of Washington program became very aware of their own frequent tendency to give up when the clients gave up. In such instances, it is essential that team members go into high gear to keep the therapists involved in the treatment.
A third task is to develop a process for handling therapists’ termination from the DBT team. Leaving can be difficult because a tremendous sense of intimacy often develops, at least on long-running teams. There may also be a few instances when a therapist simply cannot or will not learn DBT sufficiently to put it into practice. Although this is rare, when it occurs it is similar to a treatment that does not lead to client improvement. Managing termination here is fraught with the same difficulties a therapist has in ending an unsuccessful therapy. For a person who wants to learn DBT but simply cannot “get it,” the team may want to suggest additional coursework in areas of weakness. For example, a therapist on a University of Washington team was extremely motivated to learn DBT individual therapy. However, he had no background whatsoever in behavioral therapy or theory, and no amount of teaching on the team could overcome the deficit. The team finally asked him to audit several graduate courses in behavioral change. He did so, returned to the team, and became one of the best therapists on the team.
Termination from a second phase of treatment can vary for clients, depending on the modality of treatment they have been receiving, the progress they have made, and their plans for continuing some form of treatment. When individual therapy has continued, termination is considered when therapist and client agree that goals of a second phase of treatment have been accomplished, which often correspond to achieving DBT stage 2 and 3 targets. When some form of graduate group has been the modality, termination may come at the end of a full cycle of the group. However, a leader can also invite an adolescent who needs or desires continued group therapy to continue for another cycle. As noted earlier in this chapter, some graduate group members choose to recontract once, twice, and sometimes more before they officially graduate from the program. At that time, another graduation ceremony takes place.
In addition to the ritual described in Chapter 10 and above for clients moving on from the multifamily skills group, clients moving on from our graduate groups receive a more sophisticated diploma and a DBT tool kit. These kits contain items identified by the former individual therapist, former skills trainers, and current group leaders. For example, one adolescent female received distress tolerance tools (a “stress squeeze” ball and a small bottle of her favorite scented moisturizer) and mindfulness/emotion regulation tools (a journal for writing her thoughts and a pad for sketching, both of which the client considered pleasant activities). Therapists enjoy tailoring these DBT tool kits for each adolescent. Graduate groups typically become intense experiences for their members. The ending of this phase of treatment marks a substantial length of participation in the program, and clients often feel highly committed to the group and connected to one another.
In a sense, the entire concept of the graduate group prepares adolescents for termination. Adolescents have now mastered skills, and have typically made the transition from individual therapist intervention to a more peer-focused model in group. In the particular graduate group model used at Montefiore, adolescents must master skills to the point of teaching them to their peers, and follow a peer coaching model of treatment. Family members go from weekly contact to occasional family sessions that are held only if needed. Thus this phase of treatment is set up not only to reinforce and strengthen what was learned, but also as a fading process. As mentioned earlier, this fading to a group modality without parental involvement, with greater self-teaching and greater peer coaching, parallels an adolescent’s normal developmental process. This graduate group mode may thus be uniquely important for adolescents, as they simultaneously strive not only to maintain their treatment gains and prevent relapse, but to master the developmental tasks of separating and individuating from parents and authority figures—and thus preparing for the greater self-sufficiency of adulthood.
This chapter is intended to help therapists gauge progress in treatment, to run a graduate or advanced group, to prepare clients for the transition to the next phase of therapy, and to handle the completion of therapy. Thus far, this volume has described the implementation of DBT with adolescents, from setting up a program and assessing client progress to terminating treatment. In the next and final chapter, we address program issues and practice barriers that can pose challenges to setting up and running effective DBT programs for adolescents.