The acceptance focus draws upon principles of Zen and other Eastern spiritual traditions. Therapists teach patients to accept reality as it is in this moment, without judgment. A key extension of this acceptance is the use of validation—radical acceptance and acknowledgement that all behavior has validity and understandability. DBT therapists strive to use 6 levels of validation with their patients ( Table 2 ),16 which often is a critical strategy for adolescents who reside in an invalidating environment.
DBT attempts to synthesize the acceptance-based Zen tradition with the change-based strategies of behavioral science through a dialectical philosophy. A fundamental postulate of dialectical philosophy is that a tension occurs when an initial truth or thesis is opposed by an apparently contradictory truth or antithesis.8 DBT therapists work with adolescents to find a synthesis that is the “middle path, “ which includes the truth in both positions as well as what is left out of both. For an example of how this might work for an adolescent patient with NSSI, visit this article at CurrentPsychiatry.com.
Table 1
Characteristics of an invalidating environment
| Characteristic | Result |
|---|---|
| Indiscriminately rejects communications of private experiences | Adolescents learn to actively self-invalidate and do not learn to validate themselves, label their emotions, or effectively regulate their emotions |
| Actively punishes displays of emotions, interspersed with intermittent reinforcement of emotional outbursts | Adolescents develop problematic emotion regulation strategies that oscillate between suppression and extreme outbursts |
| Oversimplifies problem solving | Adolescents develop high perfectionism and sensitivity to perceived failure, form unrealistic goals, and experience intense negative arousal in response to challenging feedback |
| Source: Reference 8 | |
Table 2
6 levels of validation employed by DBT therapists
| Level | Validation practices |
|---|---|
| Accurate reflection | Paraphrase what an adolescent says; communicate that you accurately understand what the adolescent has said |
| Mindreading | Communicate that you understand the adolescent’s private experiences or that which is unsaid. Articulate private experiences of the adolescent based on your knowledge of him or her |
| Observing and listening | Use nonverbal and paralinguistic cues to indicate interest. Communicate that you wish to know the adolescent’s emotions, thoughts, and behaviors |
| Validating in terms of causes | Make sense of behavior based on the adolescent’s learning history or biology. Describe how a behavior is effective for short-term but not long-term goals |
| Validating in terms of the present | Search for and reflect the wisdom and truth in the adolescent’s behavior by saying things such as ‘Of course you feel this way! Anyone would feel the same in your situation’ |
| Radical genuineness | Act natural, like a real person, rather than a ‘therapist. ‘ Communicate belief and confidence in the adolescent |
| DBT: dialectical behavior therapy | |
| Source: Reference 16 | |
How DBT works
DBT serves 5 functions. It enhances patient capabilities, increases patient motivation, structures the environment to increase the likelihood of success, works to assure generalization from therapy to the natural environment, and enhances therapists’ capabilities and motivation to treat patients effectively.8 Outpatient DBT for suicidal adolescents uses 4 modes of treatment:
- weekly individual therapy
- weekly skills training
- telephone coaching
- weekly therapist consultation team meetings.8
Although Linehan’s original research with adults was based on a 1-year treatment model,17 treatment lasts 12 to 16 weeks in the adolescent DBT model designed and studied by Miller et al.8 Treatment for adolescents is shorter because research indicates that suicidal adolescents frequently fail to complete longer courses of therapy.18
Individual therapy. The rank-ordered targets of individual therapy in the first stage of DBT are to:
- eliminate life-threatening behavior, including NSSI
- stop therapy-interfering behaviors (eg, not showing up to sessions)
- change behaviors that interfere with the adolescent’s quality of life (eg, substance abuse)
- enhance the adolescent’s use of skills.8
The individual therapist sets treatment goals in accord with these targets, monitors progress, integrates all modes of therapy, and balances acceptance and validation of the patient with being a catalyst for change. Family members may be included in therapy sessions when family problems emerge as the highest priority.
DBT therapists use chain analysis—which is a process of assessing the series of events, link by link, that lead from a prompting event to a problem behavior (eg, suicide attempt)—to assess problematic behavior and identify methods of change.8 The therapist and patient use this process to develop alternative behaviors for the patient to use to reach a more effective outcome.
DBT therapists also ask adolescents to fill out a daily diary card that tracks targeted behaviors, including NSSI, suicidal urges, and important emotions. The diary card helps the therapist determine what needs to be targeted in therapy, increases mindfulness and understanding of problem behaviors, and helps change targeted behavior.