This feature by Lorie Ritschel, PhD is Part 2 of 2 in a series about DBT for adolescents. In the first part, Lorie addressed her experience as a DBT therapist working with adolescents and a couple of notable differences between DBT and DBT-A. In this part two, we will address caregiver therapy interfering behavior.
While DBT with adolescents has considerable overlap with standard DBT, there are several notable differences. In part 1, we explored the importance of the Walking the Middle Path module in skills training groups as well as the way that DBT-A was designed to systematically include caregivers with the goal of increasing the likelihood of skills usage and reinforcement in the home environment.
Which leads us to a third factor that differentiates DBT-A from standard DBT: the need to address caregiver therapy interfering behavior.
Linehan (1993) defines therapy interfering behavior as “any behaviors that interfere with the therapy process” (p. 175), though, as we all know, Marsha’s book was written for the treatment of adults. As DBT is a principle-driven therapy, however, it stands to reason that the principle of addressing TIBs extends to caregivers and families who are interfering with treatment, either directly (e.g., making fun of DBT skills; refusing to allow a teen to call the therapist for coaching, failing to get the teen to their appointment on time) or indirectly (e.g., belittling the therapist to the teen, refusing to practice skills to regulate their own emotions).
As is the case in standard DBT, therapists must be mindful of which behaviors increase their burnout or cross the limits of the clinic or program in which they work. For example, some clinics set rules around how high an outstanding bill is allowed to get before sessions are suspended, or the clinic may not have a workaround or exception for a teen whose caregiver refuses to attend skills training group. Such rules must be communicated to families and clients early and often so that treatment is not disrupted.
Caregivers may also engage in behaviors that burn the therapist out even when the teenager themselves is not engaging in TIBs. In the absence of a clinic-issued rule, each therapist must mindfully observe if, how, and to what extent the caregiver’s behavior(s) decrease the therapist’s limits to work with the teen.
In one of my favorite examples, I had a client whose mother referred to me as “Dr. Bitchell” (but only when I was not within earshot). While this was not my preferred moniker, I did find it somewhat humorous and it actually bothered me very little (apparently she referred to me that way one day on a group break, and the remainder of the group gave her feedback about how inappropriate that was, especially for a parent to say in front of teens – thank you, natural consequences!). In the same case, this mother also engaged in behaviors such as (1) telling the teen to choose between doing her therapy homework or joining her family to watch a movie; (2) standing in the doorway of my office in the clinic and yelling expletives at me along with commentary on my competence; and (3) demanding that the teen audio record our sessions for use in divorce proceedings without my knowledge or consent (which was also against clinic policy).
Again, I get why people are scared off by parents.
Back to the point, though – while I didn’t care about the unfavorable nickname, I cared quite a bit about a kid having to choose between therapy homework and a family event. I also cared a lot about the audio recording, though it didn’t matter if I cared or not, because that was a no-go from the clinic perspective. Regardless of how much I cared or didn’t, all of this (except the nickname) needed to be addressed or I knew where we were headed.
I use this as an exemplar, because it was by far my highest burnout case at the time, and almost none of my burnout was caused by my actual client. The good news is that we did address TIBs directly, and they did decrease to a more manageable level, though it took a lot of contingency management and a decent helping of both the wave skill and opposite action on my part. In addition, though, it presented me with the absolute best possible way to model effective behavior for my client, including the chance to walk a vulnerable teenager through my thought process about how, when, and how intensely I decided to respond to various TIBs that occurred and which skills I used to maintain my equilibrium. In turn, this gave her a springboard for trying new things to advocate for herself.
I love working with this age group, as you can probably tell. I have had the chance to watch families shift from overwhelming bitterness and resentment (including considering turning their children over to be wards of the state) into communicative, effective, even loving relationships. I’ve been doing this long enough now that every spring I get a few graduation announcements from former clients – some finishing high school, some finishing college, some even going on to their own careers in mental health. I’ve gotten tearjerker notes from parents expressing their gratitude because they weren’t sure their child would be alive by the end of high school.
To say that this work is rewarding is a massive understatement. Of course, it comes with some bumps in the road, but none of us got into this work because we were looking for something easy.
Lorie Ritschel, PhD is a certified DBT therapist through the DBT-LBC and is an expert trainer of DBT and the DBT Prolonged Exposure protocol. She is a co-founder of the Triangle Area Psychology Clinic (TAP), an outpatient clinic in Durham, NC that specializes in DBT and other empirically supported treatments for adolescents, adults, couples, and families.. Read her full bio here.