Treatment Spotlight: Family DBT at Evolve

[This article is based on a lecture presented recently by our Clinical Director, Dr. Lauren Kerwin]

As you may know from reading our article Treatment Spotlight: Dialectical Behavioral Therapy (BDT) at Evolve, DBT is all about change. From emotions to behaviors to modes of thinking, the essence of DBT lies in learning how to transform life-interrupting thoughts, emotions, and actions to life-affirming thoughts, emotions, and actions. We take a comprehensive approach to treatment in order to address all aspects of our adolescent’s lives. We look at their physical, emotional, social, and spiritual simultaneousy. That’s why we engage families directly in the therapeutic process as much as possible. Family is part of the big picture. We can do all the work in the world with a teenager. They can make amazing progress while they’re here with us. But if the family is not involved in treatment, then the chances of a successful outcome are significantly reduced.

Why?

Because no one lives in a vacuum.

Family Systems

Every individual grows and matures as part of a group of humans who have a direct impact on their development. The actions of any individual member of that group affect the dynamic of the whole group, and the collective norms and behavior of the group affects the actions of individual group members. This is a basic tenet of Family Systems Theory, which informs our approach to family involvement in our residential DBT programs.

Here’s another way of expressing the Family Systems concept:

  1. Each individual is part of a complex system of relationships, which, for the sake of efficiency, we’ll call a family.
  2. The dynamics of the family contribute to the development of the individual.
  3. Therefore, the behavioral patterns the individual develops – including substance use or mental health issues – are influenced by the relationship dynamics of the family in which the individual grew up.

Family relationships form the foundation of how your teenager experiences the world. They shape their attitudes, opinions, choices, and behavior. When your teenager begins residential treatment at Evolve, it’s critical for you to learn as much as you can about the changes they need to make to achieve sustainable mental health and sobriety. For those changes to stick, you’re going to have to make changes, too. Sometimes the changes are small, sometimes they’re large – whatever the case happens to be for your family, a growing body of evidence shows that when families are involved in the treatment process, good things happen.

Positive Outcomes of Family-Centered Treatment
  • Rates of substance use decrease
  • Rates of relapse decrease
  • Time spent in treatment increases
  • Behavioral issues such as aggression and opposition decrease
  • Symptoms of co-occurring emotional issues such as depression and anxiety decrease
  • School performance measures such as grade point averages and attendance improve
  • Family relationships improves
  • Family discord deceases

We’re sure you want all those positive changes for your teenager and your loved ones. And while those things are easy for us to simply write and share with you, it takes work to get there.

So how do you get there?

And once you get there, how do you make these positive changes last?

Family DBT At Evolve: The Middle Path

Our approach to Family DBT is based on a treatment module developed by Wise Minds called The Middle Path. Like many aspects of DBT itself, the concept of The Middle Path applies ideas found in mindfulness practices, which in turn use ideas derived from Zen Buddhism, such as:

  • Accepting the world as-is, non-judgmentally, in the here and now, without trying to change it.
  • Understanding there is more than one way to see a situation or solve a problem.
  • Validating everyone’s perceptions and experience of a situation or set of circumstances.
  • Validating your own perceptions and experience of a situation or set of circumstances.
  • Believing that change comes through action guided by mindful thought. Through acceptance, understanding, and validation, you can change how you react both internally (thoughts and feelings) and externally (words and behavior) to your situation and circumstances.

In application, The Middle Path asks families to avoid defaulting to points of view that embrace extremes. We encourage families to see things not as black and white or all or nothing, but rather to explore the gray area between those extremes and understand that fertile ground for positive change exists in the space between polar opposites. Family conflict often arises when one party – sometimes the parent, and sometimes the child – becomes so entrenched in their perception of reality they’re unwilling to accept reality as it is, compromise, and move forward toward a mutually beneficial solution.

The Challenge to Change

We ask our teenagers in residential treatment to face this aspect of themselves every day. We challenge them to drop the zero-sum thinking and open their minds to new possibilities. When families engage in the therapeutic process, we ask the same thing of parents: we challenge them to let go of their previous modes of thinking and open themselves to new ideas about both parenting and their relationship with their children. Research shows three primary areas where parents get stuck in the extremes, and need help navigating the middle path:

Disengaged/Excessive Leniency vs. Authoritarian Parenting Styles

You may recognize these terms because over the past twenty-five years they’ve become mainstays of what we affectionately refer to as Parenting Lingo 101. The Permissive and Authoritarian styles represent two extremes of a continuum that identifies four common approaches to parenting: Authoritarian, Authoritative, Permissive, and Disengaged. Authoritarian parents lay out rigid rules and consequences and enforce them in a rigid, my-way-or-the-highway manner. Authoritative parents communicate clear rules and consequences for children and enforce them in a loving and supportive environment. Permissive parents lay out few rules but tend not to enforce consequences while providing a loving and supportive atmosphere. Disengaged parents tend to be absent as authority figures, set neither rules nor enforce consequences and don’t engage either positively or negatively with their children.

Disengaged vs. Authoritarian: Both Too Extreme for Teens

Research shows what you might expect: the Authoritarian and Disengaged styles cause problems, particularly with regards to drugs, alcohol, and problem behavior. It’s easy to understand why. Teens tend to rebel when parents present rules as if they’re set in stone, but when they understand the why behind rules, they’re more likely to follow them.

On the other side of the continuum, the Disengaged style of parenting – characterized by an absence of rules, boundaries, and consequences – gives teens too much leeway. When they make mistakes or break what rules do exist, they don’t experience significant consequences. Therefore, they don’t learn valuable lessons that lead them toward mature and responsible life choices, and away from drugs, alcohol, and problem behaviors.

Studies indicate the Authoritative and Permissive styles – both of which occupy the middle ground between two extremes – are the most effective approaches with regards to teen behavior around drugs, alcohol, and problem behavior. The DBT Middle Path module helps parents – in collaboration with our therapists – find out which style works best for them, their teen, and family.

Normalizing Pathological Behaviors vs. Pathologizing Normal Behaviors

When your teen was a toddler, there were probably days when you thought you lived with an unhinged, violent sociopath with no regard for the feelings of others. They were willing to scream, cry, and use physical violence to get what they wanted. But then you talked to other parents and realized those behaviors are normal – for a toddler. The teenage years present a similar conundrum: how do you discern between typical teenage behavior and dysfunctional behavior?

Typical adolescent behavior includes mood swings, boundary pushing, experimentation with sex, drugs, and alcohol, rapidly changing identities, and a dramatic, topsy-turvy social life. All these behaviors overlap with symptoms of severe emotional and substance use disorders. The challenge for parents and teenagers lies in finding the middle ground between pathology and normalcy. Both parties must learn to discern the difference between behavior that’s age appropriate and productive and behavior that’s dysfunctional and has long-term, negative consequences. It’s a tough nut to crack, and often requires the help and support of a trained mental health professional. Parents, teens, and therapists collaborate to determine what’s what. Teens learn to look within to identify the root motivation behind their behavior, while parents learn to look within to ensure they’re neither overacting to typical behavior nor underreacting to dangerous behavior.

Fostering Dependency vs. Forcing Autonomy

This is another practical conundrum foreshadowed by a question you wrestled with when your teen was a toddler: when is helicopter parenting helpful and when is it harmful? Do you let your child find natural limits at the playground or do you jump in every time there’s a slight chance they might hurt themselves? Do you micromanage tricky social interactions with other kids, or do you let them sort things out for themselves? The teenage equivalent of these questions revolves around determining the difference between appropriate vs. inappropriate levels of dependence and appropriate vs. inappropriate levels of autonomy.

The Work for Parents

Parenting involves pursuing two sometimes contradictory goals: on the one hand, your job is to protect your children from harm, while on the other hand, your job is to teach them how become independent, self-sufficient adults. Fostering too much dependency results in a clingy teen unable to make decisions for themselves, while forcing autonomy too early can result in poor, uniformed decisions and feelings of abandonment. The DBT Middle Path module helps parents find the middle ground between these two extremes.

The Work for Teens

Teenagers need to learn when to rely on their own instincts and judgment and when to seek help and guidance from their parents or other adults with real-life experience. The DBT Middle Path module helps teens find the middle ground between the excitement of independence and the comfort of dependence. This is another tough nut to crack, just like identifying the difference between typical teen boundary-pushing and dangerous dysfunction. Families who have difficulty finding balance welcome the input of a therapist or mental health professional, who can offer an objective opinion – supported by data and research – on what supports their teen’s natural trajectory toward adult independence and what hinders their healthy growth, learning, and path to self-sufficiency.

The Dynamic Interplay of Fundamental Opposites

Classically speaking, dialectic or the dialectic method is the practice of discovering truth by purposefully creating a dialogue between two individuals with opposing viewpoints. You can trace its roots from the present day back to antiquity. From 20th century sociopolitical discourse to post-Enlightenment philosophy to Greek and Roman thought to the spiritual teachings of Buddhism and Taoism, the operating principle of the dialectic method is that the process itself effectively weeds out falsehoods, dispels misconceptions, and encourages the type of lively, informed debate that results in productive, fact-based compromise.

Family Dialectical Behavioral Therapy at Evolve creates a similar outcome by employing The Middle Path module. Parents and teenagers learn tools to break free from their habitual patterns of thought and behavior. Patterns that, whichever way you slice them, resulted in residential treatment for the teen. Breaking these patterns can lead to find practical solutions that promote growth and restore balance to the family. The resulting compromise is often something neither the parent nor the teen would have considered before entering the dialogue. And that’s the entire point. Families seek help because they face challenges they’re unable to overcome by themselves. Parents and teens retreat to their corners, unwilling to let go of opposing points of view. They’re in a dysfunctional stalemate. The Middle Path gives them a way out, a way forward, and a way to restore harmony that’s based on communication, collaboration, and mutual respect.