Dialectical Behavior Therapy for Suicidal Latina Adolescents: Supplemental Dialectical Corollaries and Treatment Targets

Introduction

In 2011, the Youth Behavior Risk Surveillance System found that 21% of Latina adolescent females seriously considered a suicide attempt (SA) during the past 12 months and 14% had engaged in at least one suicide attempt (Centers for Disease Control and Prevention). These SA rates were higher than those for African-American (8.8%) and Caucasian-American adolescent females (7.9%). At Montefiore Medical Center’s Adolescent Depression and Suicide Program in the Bronx, NY, the majority of patients are Latina adolescents. Our team conducted studies with Latina adolescents, parents, and treating clinicians with the goal of improving our treatment protocol for this high-risk group (Germán, González, & Rivera-Morales, 2013; Germán, Haaz, Haliczer, Bauman, & Miller, 2013).

A promising treatment for Latina adolescents who are suicidal is dialectical behavior therapy (DBT), an evidence-based treatment originally developed for adults with borderline personality disorder (BPD) who were chronically suicidal (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan et al., 2006; Van den Bosch & Verheul, 2007; Verheul et al., 2003). Dialectical behavior therapy was adapted for use with teens by Rathus and Miller (2002). Studies comparing DBT to treatment-as-usual conditions have shown promising results in reducing deliberate self-harm behavior, psychiatric hospitalizations, suicidal ideation, depression, hopelessness, and borderline personality disorder symptomatology (Mehlum et al., 2014; Rathus & Miller, 2002).

Marsha Linehan (1993) proposed that individuals who engage in suicidal and nonsuicidal self-injurious behaviors (NSSI) with a diagnosis of BPD often resort to extreme behavioral patterns, which are referred to in DBT as dialectical dilemmas. When these patterns occur, the individual shifts between polarized behavioral extremes in an effort to regulate his or her emotional state. However, these patterns are ineffective and often function to over or under regulate the individual’s emotions and behaviors, and are thus deemed as “dialectical failures.” Accordingly, Linehan (1993) developed treatment targets to find a synthesis between the extreme behavioral styles by decreasing these maladaptive behaviors (e.g., active passivity, apparent competence, self-invalidation) and increasing adaptive behaviors (e.g., active problem solving, effectively asking for help, and self-validation). See Linehan (1993) for a full review of the original DBT dialectical dilemmas.

In working with adolescents who have multiple problems and BPD features, Miller, Rathus, and Linehan (2007) described additional extreme behavioral patterns that were transactional in nature and occurred between the adolescent and his or her environment. They identified three dialectical dilemmas specific to working with adolescents and their parents (i.e., excessive leniency versus authoritarian control, normalizing pathological behaviors versus pathologizing normative behavior, and fostering dependence versus forcing autonomy). These dialectical dilemmas have been helpful to conceptualize adolescents’ and their parents’ problematic behavioral patterns and to further formulate appropriate treatment targets.

Based on our research findings and clinical observations of Latina adolescents and families, the current authors expand upon the existing adolescent dialectical dilemmas by proposing supplemental dialectical corollaries frequently observed in Latino families. We first review the existing adolescent/family dialectical dilemmas, and then discuss the dialectical corollaries. Our goals are to provide additional interpretations of the adolescent dilemmas to foster a better understanding of the extreme behavioral patterns that can manifest in Latino families and better inform our treatment targets and strategies.

Brief Review of Adolescent Dialectical Dilemmas¹

Excessive Leniency versus Authoritarian Control

Parents² often waver between two extremes in this dilemma. Excessive leniency refers to parents being overly permissive by making too few behavioral demands on their teens. Authoritarian control refers to the opposite—parents being too punitive. An example of excessive leniency is when parents do not enforce consequences for their daughter skipping classes because they believe that she may engage in self-harm behaviors if she receives a consequence. Therefore, parents may be left feeling resentful, powerless, confused or guilty as they believe that their parenting behavior isn’t in line with their personal values. In this example, as time passes and the parents’ lack of enforcing appropriate consequences continues, the adolescent’s emotional and behavioral sequelae often intensify (e.g., she now cuts school more frequently, is failing all of her high school classes, and is violating curfew).

Eventually, this extreme behavior typically crosses the parents’ limits and may result in a strong behavioral response to control their adolescent’s other egregious behaviors. Parents may then oscillate to the authoritarian pole (e.g., parents may ground the adolescent for “the entire school year”), regardless of their anxiety about worsening their teen’s self-harm behaviors. The authoritarian response may induce hopelessness in the adolescent and often results in the adolescent giving up and reengaging in extreme high risk behaviors (e.g., NSSI).

Normalizing Pathological Behavior Versus Pathologizing Normative Behavior

This dilemma involves parents becoming desensitized, overlooking or minimizing their adolescent’s high risk behaviors (e.g., self-injury, abusing alcohol, drunk driving) while pathologizing or becoming overly focused on their adolescent’s less extreme or developmentally normative behaviors (e.g., questioning authority, occasionally cutting a class, experimenting with marijuana, etc.). In this dialectical dilemma, it is challenging for parents and adolescents to identify what is “normal versus abnormal” adolescent behaviors. Often times parents’ judgments have been distorted by past experiences in which their adolescent attempted suicide or was hospitalized psychiatrically. As a result, their “parental compass” becomes askew and they often need help to make non-mood-dependent parenting decisions. Parents are confronted with combating desensitization to harmful adolescent behaviors and appropriately attending to them.

Fostering Dependence Versus Forcing Autonomy

Fostering dependence refers to parents engaging in behaviors that stifle the adolescent’s natural movement towards autonomy. Parental behaviors that foster dependence (e.g., excessive caretaking, not allowing their seventeen year old to date) often stem from parents’ fears that allowing independence would inevitably result in reduced protection of their emotionally vulnerable adolescent from dangerous outcomes (e.g., another suicide attempt). In contrast, forcing autonomy refers to an abrupt change in parental expectations and behaviors that pushes the adolescent to behave and function independently with little to no adult guidance. Parents may dramatically loosen or sever ties with their adolescent, expecting her to make decisions about such things as therapy, school, and prescription drug use. Parenting behaviors that force autonomy may result from the parents feeling hopeless, exasperated, or burnt-out in response to the adolescent’s on-going problematic behaviors or they may be a function of an accumulation of the parents’ preexisting overburdened family system. Parents may vacillate from one extreme to the other. For example, parents may not allow their daughter to date until she is eighteen; however, upon learning that she has become pregnant the parents may then kick her out of the house demanding that she now support herself and her unborn child.

Dialectical Corollaries Specific to Latino Adolescents and Families

Examination and discussion of our research findings and clinical experiences with Latino families resulted in the formulation of two additional extreme behavioral patterns; we refer to these as dialectical corollaries. These dialectical corollaries expand on the aforementioned adolescent/family dialectical dilemmas specifically for Latina adolescents and families and provide further interpretations of the extreme behavioral patterns. The dialectical corollaries include: 1) old school versus new school and 2) overprotecting versus underprotecting.

We propose that old school versus new school is rooted in cultural and generational factors that possibly contribute to why some Latina adolescents, especially those whose families recently immigrated to the United States, engage in suicidal behaviors over time. Overprotecting versus underprotecting is linked to Latino parents who have experienced past abuse or life-threatening extreme adverse events. We propose that parental exposure to such events has critical consequences for their parenting behaviors (Germán et al., 2013a). Below is a detailed description of these new dialectical corollaries, clinical examples, treatment targets, and recommended therapeutic techniques to more effectively target change in Latina suicidal adolescents and their families.

Dialectical Corollary #1: Old School Versus New School

Old school refers to an extreme parenting style in which parents have a rigid and inflexible adherence to the norms by which they were raised, typically stemming from their country of origin. These norms include expectations about age-appropriate behaviors, values, parenting practices, and parent-child interactions. Even when Latino parents were raised in the U.S.A., they often adhere strictly to the norms of their immigrant parents³. Previous research has shown that traditional Latino families have some norms about parenting practices, parent-child interactions, and values that differ from U.S. norms. For example, Latino children are expected to exhibit high degrees of control over their behaviors, particularly in public, and normative parental discipline practices often include the use of physical restraint or corporal punishment (Barker, Cook, & Borrego, 2010; Calzada, 2010). Researchers have also found Latino families more strongly emphasize adolescents’ duty to take care of younger siblings compared to Caucasian families (Fuligni & Pedersen, 2002). One cultural value that holds great magnitude in Latino families is respeto (i.e., respect). In general, the value of respeto places a greater emphasis on obedience compared to the American value of “respect” (Andres-Hyman, Ortiz, Anez, Paris, & Davidson, 2006).

Clearly, it is important for clinicians to assess the extent to which the Latino parents they work with adhere to these traditional norms and to not make assumptions about parents’ values and behaviors. The research conducted in our clinic with our Latino population has highlighted the importance placed on the value of respeto in the parent-adolescent relationship (Germán et al., 2013a). Specifically, we observed that adolescents were taught not to question, argue, or negotiate with their parents given that this manner of interaction was deemed disrespectful when the parents were growing up. For parents who adhere to these old-school Latino norms, violation of these expectations by their teenagers is perceived as deviant within the family system, unacceptable to the parents and extended family members, and perceived as potentially dangerous by the parents especially if families live in high-crime neighborhoods.

The old-school pole may also involve significant influence from extended family members. Some Latino parents report getting criticized for not being able to properly control their adolescent’s behavior or for having their teenager receive mental health treatment. Parents consequently report feeling shamed by their extended family. This judgment often leads parents to keep their parenting struggles to themselves and/or to not participate in their adolescent’s treatment. As such, deviation from old school values may result in the Latino parents’ development of cognitive distortions of themselves as “weak” or a “failure”.

We propose that strict adherence to the old-school pole may be one contributing factor in the development of the dialectical behavior pattern called authoritarian control. As noted previously, parents that manifest this extreme parenting behavior stifle their adolescent’s increasing desire for autonomy, and apply excessive punishments or other methods to exert control. Based on clinical research (Germán et al., 2013a, 2013b), we find that parents of suicidal, Latina adolescents often limit their teen’s autonomy before they started engaging in self-harm behavior (e.g., many of our Latina adolescents reported being unable to participate in after-school activities, go to the park or store after school with friends, attend non-family parties, or date). Latino parents often expressed the belief that their parenting behaviors were normative, considering what was typical of the time and place they were raised. Researchers have reported that in Puerto Rico, the Dominican Republic, and other Latino countries from which the families in our program immigrated, alternative social structures and practices enabled adolescents to socialize with peers (i.e., large extended family networks); yet in the process of immigrating to the U.S.A., these networks often were lost (Kulberg et al., 2010; Peña et al., 2011).

New school sits opposite old school in this dialectical corollary, and refers to a rigid adherence to the current era and the dominant culture’s norms, values, parenting practices, and parent-child interactions. Latina adolescents in our program typically fall at this end of the continuum. Whereas the old-school pole involves the influence of extended family members, the new-school pole involves influence from peers, teachers, and the media in the U.S.A. Latina teenagers who attend American schools have more exposure to and contact with the social mores of dominant culture compared to their parents, who may continue to have much less exposure. In contrast to the traditional Latino norms described previously, normative behaviors for teenagers in America include a mild-to-moderate degree of negotiations with parents, and a parental tolerance for increased argumentativeness, dating, attending parties and sleepovers (Steinberg, 2005).

Latina adolescents within our studies often compared their lives to that of their peers, many of whom were also Latina but came from more acculturated families in which they were granted more autonomy (Germán et al., 2013a). Latina teens often expressed that their parents “should” allow them more liberties (e.g., attend parties with peers, have the same [later] curfew as peers, etc.) When adolescents were not granted these privileges, they often felt they had the right to question and repeatedly negotiate with their parents, as they had observed these interactions between their friends and their parents. Consequently, many of our Latina teens would engage in these restricted and forbidden behaviors (such as dating) in secret. We propose that this friction in beliefs and values lead parents and adolescents to both feel disrespected and invalidated, thereby increasing their levels of parent-teen conflict. Over a period of months or even years, this conflict became chronic. The resulting tension, coupled with the adolescents’ deficits in emotion regulation, was found to frequently precipitate the teens’ suicidal behaviors as a means to temporarily escape their uncomfortable negative emotional states. This behavior often further reinforced the polarization between parents and their adolescents, frequently causing the frightened parents to adopt an even stricter parenting regimen. Therefore, this old school manifestation exists as both a precipitant and consequence of the adolescent’s suicidal behaviors.

Clinicians sometimes inadvertently enter into these polarities as well. Many of our Latina adolescents disobeyed their parents’ strict orders in order to conform to the new school norms. While keeping such violations from their parents, they would disclose their behaviors to their clinicians (Germán et al., 2013b). In turn, some clinicians described how they developed a “secret keeper” role (i.e., trying to maintain the therapeutic relationship and the adolescent’s confidentiality by withholding information from parents, yet attempting to attend to parental concerns and improve parent-adolescent communication). This dilemma was often further complicated by clinicians feeling pulled to one end or the other of the old school versus new school continuum due to their own generational and cultural background.

Based on standard adolescent DBT protocol (Miller et al., 2007), clinicians understandably spend more time listening to and validating the adolescent’s view in individual sessions. Therefore, the therapist may feel more empathic and prone to reinforce the adolescent’s new school ways. The clinician must be careful to “honor the old school ways” and validate the parents’ concerns when working towards a synthesis to resolve conflict between the parents and adolescent; otherwise, parents may feel invalidated. This sense of parental invalidation may further strengthen their polarized positions, often resulting in a therapeutic impasse.

Old School Versus New School Treatment Targets:Incorporating Aspects of Both Cultures

The treatment target for old school versus new school entails helping parents and adolescents incorporate aspects of both cultures by increasing validation and dialectical thinking.

Clinician Strategies for Parents

Clinicians should conduct at least one collateral session that focuses on strengthening rapport with the parents. While it may start with parental concerns about their teenager, the focus should shift to a discussion and validation of the parents’ childhood experience. Clinicians should assess, attempt to understand, and validate the advantages of the old school ways. For instance, respeto emphasizes obedience and has been linked to raising children who are perceived by parents and extended family as being bien educado (i.e., well-mannered). Children adhering to these cultural ideals exhibit behaviors such as not interrupting adults without saying “excuse me,” having a polite disposition, and accepting parental decisions with little to no arguing. Latino parents who have children who are bien educado are considered to be “good parents” by extended family members (Peña et al., 2011). They receive positive reports from teachers regarding their child’s comportment at school, and worry less about their adolescents getting into trouble for challenging authority, such as the police (Fuligni, Witkow, & Garcia, 2005). Validating the positive qualities of these old school ways will strengthen the clinician’s alliance with parents.

After the clinician senses that the parent feels more understood and validated, the clinician should discuss the potential disadvantages of the old school ways. For example, many Latino parents in our clinic believe administering physical punishment with a belt or shoe is a normative parenting practice because this was used when they grew up. However, presently, in many parts of the United States (such as New York State), corporal punishment (i.e., striking a child with an object and leaving a mark) is defined as excessive, and state law requires the clinician to report such incidents to child protective services. Thus, while corporal punishment may be intended to instill respeto or decrease child misbehavior, it can have adverse consequences for both parents and teen (e.g., child welfare agencies conducting investigations). Clinicians can validate the parents desire to raise a well-mannered, respectful child, while highlighting that the parenting behavior itself is not effective in this current cultural environment.

In order to help parents validate their adolescent’s experience, we recommend clinicians prompt parents to reflect on how they felt as teenagers when they perceived their parents to be overly restrictive. This dialogue helps to increase parents’ mindfulness by helping them draw parallels between how they felt in the past and how their adolescent currently feels. To elicit a more empathic response toward their adolescent, encourage parents to reflect on their own teenage years and how their parents’ excessive restrictiveness may have negatively impacted relationships. It is also important to encourage parents to consider what it must be like for their teenager to struggle with multiple sets of cultural norms.

Highlighting this intergenerational pattern and the challenges of living within two cultures can foster dialectical thinking. Clinicians should help parents find the overlap between old school and new school parenting approaches, hopefully translating to a synthesis. For example, an initial middle path solution may be to allow their adolescent to “earn” privileges; the teen may spend time with their peers after school as long as she maintains a certain grade point average and keeps to a curfew for one month. Assuming this is successful, the clinician can work with the dyad to negotiate further compromises. These strategies are aimed at building a trustful alliance between the clinician and parent, which is key to supporting the adolescent’s treatment.

Clinician Strategies for Adolescents

Similar to the strategies used with parents, it is important for clinicians to begin by gaining a “location perspective” of the adolescents to fully understand their current experiences. Clinicians should start by acknowledging and validating the advantages of the new school ways (e.g., learning to be more independent prepares teens for adulthood, dating helps teens develop relationship skills). Then clinicians can explore the potential cons associated with remaining on this pole and also discuss the potential pros and cons of the old school ways. The clinician should help the adolescent identify the type of relationship that she desires with her parents and describe how maintaining behaviors consistent with only new school ways is not in line with achieving this goal. The adolescent is encouraged to empathically consider her parents’ thoughts and feelings (e.g., how her parents may feel when she dismisses their house rules) while she is focusing on achieving her own goals (e.g., later curfew). Additionally, it is helpful to increase the adolescent’s empathy in considering her parents’ challenges of living in a new place with a different set of cultural values and norms. Ultimately, these strategies are intended to help new school teens and old school parents find a middle path and improve their relationship. [See Table 1 for a summary of these strategies.]

Dialectical Corollary #2: Overprotecting Versus Underprotecting

Both overprotecting and underprotecting poles appear to be related to a subset of Latino parents who had exposure to abuse or near death experiences that had critical consequences for their parenting behaviors. We use the phrase “history of trauma” to indicate experiences of sexual, physical, or emotional abuse or threat of a near-death experience or serious injury when the parents themselves were children or adolescents. These distressing experiences may have resulted in the development of trauma symptoms, which in turn may have shaped their perceptions of the world as “unsafe” or “unfair” and prompted the development of one of these two extreme patterns of cognitive and behavioral responses.

Overprotecting refers to an extreme style in which parents maintain a rigid and inflexible adherence to the notion that the world is an unsafe and dangerous place. This notion informs the overprotecting parents’ perceptions that granting their adolescent more autonomy or freedom to explore the outside world is potentially life-threatening. This often stems from the parents’ history of trauma. These parents become overwhelmed by feelings of intense worry and consequently are very restrictive in their provision of what is allowed versus what is not allowed in terms of their adolescent’s behavior. They also often cite their own experience of trauma as “evidence” or “justification” of their overprotecting parenting behaviors. The adolescent’s failure to comply with these stringent rules typically result in the excessive punishment seen in the original dialectical parenting pattern of authoritarian control.

Overprotecting parents tend to be unresponsive and sometimes defensive toward clinicians’ efforts to introduce supervised, normative activities into the adolescent’s life. For example, a clinician may prompt overpro-tecting parents to consider compromising with the adolescent by allowing her to spend time with friends after school as long as an adult supervises them. Parents may still insist that this is an unacceptable request because they cannot trust any non-familial adult to provide appropriate supervision (e.g., the parents refuse to permit the adolescent to join the school track team). Parents that retain this overprotective stance do not consider their concerns to be disproportionate to the risk involved; consequently, they may feel invalidated by the clinician’s and adolescent’s attempts to negotiate. Accordingly, these parents find it difficult to implement the specific DBT skills of validation and perspective taking. We propose that parents’ sense of ubiquitous danger may be triggering them to respond in this unreceptive and inflexible manner. On this end of the continuum, parents view their adolescent as vulnerable and lacking the capacity to keep themselves safe.

Opposite the overprotecting pole exists the underprotecting pole, which refers to an extreme view of the world as being inherently unfair and unjust. Parents at this extreme often ruminate about their difficult childhoods, incessantly focusing on their own suffering and pain, and they tend to compare their past anguish and own painful memories of abusive or even traumatic experiences to those of their currently suicidal adolescent. Social psychologists describe this process as downward social comparison in which individuals in unfortunate circumstances attempt to enhance their subjective well-being through comparison with seemingly less fortunate others (Wills, 1981). These underprotecting parents consequently engage in minimization and invalidation of their teen by considering their adolescent’s life to be “not as bad,” and perhaps even notably better than their own childhood. They often explicitly verbalize these thoughts to their adolescent and the treating clinician. Statements such as “she’s ungrateful for her better life,” or “she doesn’t get the sacrifice I’ve had to make to raise her” are typical among this subset of parents. In this scenario, the adolescent appears to serve as a constant reminder or symbol of an unfair world or of the parents’ past abusive relationships. This pervasive invalidation of the teen often leads the teenager to shut down, feel misunderstood, and creates unjustified feelings of shame, self-invalidation, and increasing emotional and behavioral dysregulation.

Underprotection may be manifested by the parents’ minimization of the danger surrounding their adolescent’s current suicidal ideation and past suicidal behaviors. Even with the knowledge of their adolescent’s previous attempts to overdose or engage in nonsuicidal self-injurious behaviors, parents at this pole may not take the precautionary steps as directed by the clinician to keep their adolescent safe by locking up medications and sharp objects. Underprotection may also involve parental refusal (or minimal or ambivalent) participation in the adolescent’s treatment.

Another aspect of this dialectical corollary includes parents burdening their adolescent with adult-like responsibilities that often appear similar to the dialectical dilemma forcing autonomy. Rathus and Miller (2000) posit that parents at the forcing autonomy pole sever or loosen ties with their adolescent because they feel either overwhelmed by their teen’s suicidal behaviors or they want to push their teen to mature more quickly. We hypothesize that parents who underprotect engage in forcing-autonomy type behaviors with their teen because they are motivated by their own extreme childhood experiences of abuse or trauma. For example, at the underprotecting pole, parents burden their adolescents with duties that are partially similar to those imposed on them as children (e.g., excessive caretaking of younger siblings, tending to the household). This parallel is demonstrated by one parent’s statements, “When I was 14-years-old, I had to take care of all my siblings, clean the house every day, and cook so I couldn’t spend time with my friends.” Within this scenario, these enforced responsibilities on the teen are different enough from the parents’ own as a child that they are communicated to the adolescent as “easier” and hence fair. Thus, while the parenting behaviors in both the forcing autonomy dialectical dilemma and the underprotecting corollary may present in a similar fashion, the motivations underlying the parental behavior differ, and therefore, should have different treatment targets.

Overprotecting Versus Underprotecting Treatment Targets:Modifying Maladaptive Parental Cognitions

The initial treatment target for both poles is to modify maladaptive parental cognitions to facilitate more dialectical thinking patterns and behaviors. For parents on the overprotecting pole, clinicians should target their pervasive mistrust of other people, as well as their thoughts about their adolescents being incapable of learning how to keep themselves safe. Parents on the underprotecting pole differ from those in the overprotecting pole in that they often view others, including their own children, as “having it easier” than they did during their adolescence. Thus, it is important to:

Clinician Strategies for Parents

First, it is critical to help parents find their “wise minds”⁴ to assess what is and what is not working in their interactions with their teen. Second, highlighting the intergenerational parenting patterns, especially those that parents experienced as upsetting during their adolescent years, often increases empathy for their adolescent in the present moment. Third, it is important for clinicians to attend to indicators of parents’ histories of abuse, trauma, and mental health problems. Clinicians can validate parents’ past experiences using the biosocial theory, which acknowledges the parents’ emotional vulnerabilities as well as their experiences of invalidating environments. Clinicians can reframe parents’ overprotecting behaviors as attempts to protect their adolescent from the kinds of adverse experiences they experienced during their youth. The goal is for parents to work towards an authoritative parenting style such that they reward their adolescent for effective behaviors by a developmentally appropriate increase in privileges (e.g., spending time with approved peers, joining the school track team, etc.). At the same time, the clinician helps the parents increase their mindfulness of urges to restrict their adolescent’s autonomy when they experience “triggers” of their history of trauma; this exposure often results in parents applying extreme punishments, engaging in excessive rule setting, and restricting their teen’s independence.

For underprotecting parents, clinicians can reframe parents’ neglectful or angry behaviors as signs of exhaustion and needing help. Moreover, clinicians should assess parents’ maladaptive cognitions toward their teen (e.g., “Why are you so sad? When I was your age I had to raise all five of my siblings and drop out of school. All I’m asking you to do is watch your brother after school. I wish I had it that easy when I was your age.”) Increasing parents’ mindfulness about the impact of their past abuse or trauma on their current judgments and behaviors is key to changing these cognitions. At the same time, clinicians need to assist parents in finding a synthesis by honoring the truths in their, as well as in their daughter’s, perspectives. The goal is for parents to learn both how to identify triggers of their past abuse or trauma that affect current parenting practices and how to apply skills to cope with their intense emotions.

While we suggest that clinicians assess and address the influences of parental trauma in the context of the adolescent’s therapy, clinicians should be careful to abstain from directly treating the parents. The parents can and should be referred for their own individual therapy. The adolescent’s individual clinician should collaborate with the parents’ health care provider to facilitate active communication and progress toward treatment goals. Unfortunately, many of these parents have difficulty following up with referrals, and therefore clinicians can teach DBT distress tolerance skills (e.g., self-soothe, distraction techniques) for parents on both poles to use when certain triggers from their past trauma get activated (See Table 2 for a summary).

Clinician Strategies for Adolescents

For overprotected and underprotected adolescents, it is useful not only to increase healthy relationships with peers, teachers, and romantic partners but also prosocial routines and activities outside of the home. This must be done slowly and with parental support since such activities may accidentally trigger deeply rooted maladaptive parental responses associated with the adolescents’ development and agency. It is useful to teach the adolescent to use her interpersonal effectiveness skills for communicating preferences to her parents, while explaining how achieving this positive outcome may affect her mood or behavior or make the parents life easier in some way. For example, “If you allow me to join the school softball team and practice afterschool, it would make me feel better about myself and teach me to be more responsible. I would call you before and after practice and keep my grades at a “B” average to remain on the team, which I know is important for you and Dad.”

It may be necessary for clinicians to intervene on behalf of the adolescent more than is typically recommended for DBT clinicians, who ordinarily rely on using consultation to patient strategies. Clinicians should heavily utilize other resources that provide parents with additional support (e.g., mental health treatment, case management and respite services, financial aid, housing and/or legal resources). Additionally, the clinician may assist the teenager in finding additional support and validation by identifying existing parent-approved activities and places within her community (e.g., church or other religious institution, community recreational center, extended family member or older adult sibling’s home).

Alternative Treatment Targets for Clinicians Unable to Achieve Dialectical Synthesis

We have encountered cases where clinicians were unable to achieve the suggested treatment targets with parents and adolescents. While there is no set time frame for when a clinician should “give up” or change course from suggested treatment targets, in our experience, if a clinician is unable to help parents develop suggested DBT skills during Stage One of Treatment (i.e., 20 weeks), the consequence is often an increase in depressive symptoms and hopelessness in the adolescent. After meeting with the DBT consultation team, the clinician may consider becoming more acceptance oriented and helping the teen radically accept (for now) that her parents, despite everyone’s best efforts, are not yet able to validate her vantage point or find a synthesis.

Clinician Strategies for Parents

First, clinicians need to radically accept that they were unable to shift the parents away from an extreme pole. Second, clinicians should be mindful of their judgments and feelings of frustration and they need to keep validating the parents’ challenges in finding a synthesis via collateral sessions. These sessions enable the clinician to maintain therapeutic rapport and to promote parents’ willingness to allow the adolescent to continue in treatment. It is important for clinicians to initiate periodic check-ins with parents to avoid communicating solely when the adolescent and family are in crisis (e.g., in response to an adolescent’s suicide attempt).

Clinician Techniques for Adolescents

It is important not to induce hopelessness in the adolescent; rather, the clinician can provide the adolescent with psychoeducation, explaining the reasons that may have obstructed a parent’s ability to become more dialectical at this time. The clinician works with the adolescent to help her practice not only self-validation, but also how to validate her parents’ vantage point from a biosocial perspective. This is a skill the adolescent is taught in her weekly DBT skills group. It is also important to assist the adolescent in identifying her “thinking mistakes” about the reasons that she and her parents were not able to achieve a synthesis. For example, rather focusing on than internal attributions, “my mom won’t allow me to join the dance team because I can’t be trusted”, consider that “my mom won’t allow me to join the dance team because she’s afraid that something bad will happen to me.” Teaching adolescents distress tolerance skills and emphasizing the independence that awaits many of them when they turn 18 can help counter the teen’s tendency to feel hopeless.

Conclusion

This paper described the dialectical corollaries we frequently observed in treating Latina adolescents who were suicidal and their families. Old school versus new school encapsulates extreme behaviors fueled by norms of the parents’ country of origin clashing with the adolescent’s adaptation of norms present in the current environment. Overprotecting versus underprotecting represents extreme parenting behaviors that stem from early parental exposure to trauma. The suggested treatment targets focus on enhancing mindfulness skills, validation, dialectical thinking, and correcting cognitive distortions. We have also outlined suggestions to help clinicians manage therapeutic impasses (i.e., dialectical failures).

It is important to note that the dialectical corollary of old school versus new school may be present in other immigrant dyads. Additionally, the dialectical corollary of overprotecting versus underprotecting may apply to parents from other cultural backgrounds that experienced similar histories of trauma. We hope that the aforementioned dialectical corollaries and proposed treatment targets and techniques will enhance the standard adolescent DBT protocol and improve outcomes among suicidal, Latina teenagers and their families.