Towards the Development of an Effective Working Alliance: The Application of DBT Validation and Stylistic Strategies in the Adaptation of a Manualized Complex Trauma Group Treatment Program for Adolescents in Long-Term Detention

Introduction

Although adolescent criminal behavior is multi-determined, one consistent finding is that 75% to 93% of youths entering the juvenile justice system annually “are estimated to have experienced some degree of trauma” (Adams, 2010). This is compared to 61.8% in a national sample of adolescents who were exposed to a potentially traumatic experience (McLaughlin et al., 2013). However, while only 4% of the general population develops post-traumatic stress disorder by age 18 years (PTSD), 26% to 45% of the incarcerated juvenile population fulfills DSM-IV criteria for this diagnosis (Merikangas et. al, 2010; Kerig et. al, 2009). These statistics suggest that youths in the juvenile justice system have not only been exposed to potentially traumatic events at a higher rate than their nondelinquent peers, but also are experiencing relatively more PTSD symptomatology. These statistics are supported by other researchers as well (e.g., Kerig, 2012).

Moreover, the trauma histories of juvenile offenders are often “complex” or “developmental” in nature, involving exposure to pervasive, longstanding, and ongoing trauma and extreme stress with attendant problems (e.g., behavioral and emotional dysregulation, cognitive distortions) that may not include core PTSD symptomatology, such as intrusive memories, thoughts, and feelings (Ford et al., 2012; Herman, 1992; van der Kolk, 2005, 2014). For these youths the often traumatic and stressful experience of detention can be even more damaging, and may increase their propensity for delinquent behavior after detention (Becker & Rickel, 1998; Kupers, 1996).

In light of the marked role of traumatic, extreme stress in the behavioral problems of serious juvenile offenders, it is clear that they need evidence-based, trauma-informed treatment programming (National Child Traumatic Stress Network, 2003). Although treatment in juvenile justice settings can be daunting, especially when resources for evidence-based mental health services are scarce, previous studies have shown that treatment for juvenile offenders can be beneficial. For example, mental health interventions reduce recidivism while punishment typically does not; in fact, punishment-based programs have been positively correlated with recidivism (Andrews & Bonta, 2010).

Identifying an Intervention for Multi-Problem, Incarcerated Youth with Complex PTSD

The co-therapists (the first two authors) were assigned to identify an evidence-based treatment to apply to a group of adolescent males with substantial, chronic trauma exposure histories in a detention facility located in a southeastern city of the United States. At the time, evidence-based treatments for this population were in the beginning stages of development. One such program that appeared promising was entitled Enhancing Resiliency: School-Based Group Treatment for Adolescents Living with Interpersonal Trauma (Kaplan et al., 2003). This treatment was particularly appealing for our setting because it was a unique and integrative, manualized group treatment approach. In fact, it was the only treatment available at the time specifically designed for adolescents living with interpersonal trauma, experiencing ongoing significant distress, and at risk for (or already experiencing) negative psychosocial outcomes consistent with the clinical concept of complex or developmental trauma referred to earlier. The manual by Kaplan et al. was developed by blending large elements of three established, evidence-based treatments: Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b; Linehan, Armstrong, Suarez, Allmon & Heard, 1991; Linehan et al., 2006; Miller, Rathus & Linehan, 2007), Trauma Adaptive Recovery Group Education and Therapy (TARGET, Ford et. al, 2003), and UCLA’s Trauma/Grief Group Psychotherapy Program (Saltzman et. al 2006). Since our use of the initial version of the manual in the spring of 2005, the treatment has evolved further and has been renamed Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS; DeRosa, Habib, Pelcovitz, Rathus, Sonnenklar, Ford, et al., 2006; DeRosa and Pelcovitz, 2009). Because of this, as well as the fact that the goal of this paper is primarily to highlight relational strategies rather than the delivery of cognitive behavioral principles, we will refer to the treatment manual as “the Manual” for the remainder of the paper.

Before utilizing the Manual in our setting, we contacted the manual developers directly and asked for their permission to use and potentially adapt the manual for use with a population for which it was not directly intended; they gave us their permission and expressed an interest in learning how it worked with a youth population in detention (DeRosa, R., personal communication, December, 2004). Based on clinical experience working with complex trauma-exposed and behaviorally high-risk youths and adults in a variety of outpatient, restricted and forensic settings, multiple adaptations were made to the manual during treatment. Some of these changes proved to be particularly relevant to work with behaviorally disordered youths with complex PTSD histories.

In the remainder of this paper, we provide a clinical case example of how a manualized treatment for youths exposed to chronic stress was adapted to meet the needs of a group of detained male adolescents with a documented history of high levels of trauma exposure and related problems. More specifically, we highlight how acceptance-oriented and stylistically irreverent interventions consistent with dialectical behavior therapy principles were used to engage these youths authentically. Finally, we show that this initial, relationally-focused engagement process set the stage for the group members to self-initiate a therapeutic return to the exploration of the skills-based portions of the Manual as originally designed. Therapeutically poignant moments are interwoven as appropriate not only to punctuate the most salient clinical points we hope to make, but to also bring to life the underlying tone and “spirit” of the therapeutic process that the authors believe is essential for such authentic engagement to occur in such a population of youths.

A Case Example: An Adaptation of Sparcs in a Forensic Setting

Participants

The group was held at a juvenile detention center in a southeastern city of the United States. This particular facility served as a short-term holding facility for male and female youth arrested and detained for committing a crime and awaiting adjudication. However, at the particular time that this intervention was implemented, one of the long-term male detention facilities in another area of the state had been temporarily closed. Adolescents from that facility were therefore placed temporarily at various other detention facilities throughout the state without having been given much notice about the move. A trauma-based group was requested at this particular short-term detention facility for a subset of the transferred male adolescents. Many of them had been in a mental health unit at their facility of origin, had significant trauma histories, and were struggling with extreme emotional and behavioral dysregulation in response to the sudden change.

Inclusion/Exclusion Criteria

Adolescents were assessed for group appropriateness by unit caseworkers utilizing the Youth Trauma Screening Inventory (YTSI) (Jurkovic, Zucker, Ball, and Fasulo, 2003). This clinical instrument is designed to review the history of traumatic and stressful life experiences and the impact on juvenile delinquent and similar populations at high risk for complex PTSD (see Ball et al., 2007, for a description of the measure). The only exclusion criterion for the group was intellectual functioning in the intellectually disabled range (IQ < 70), because adolescents with severe cognitive limitations might not be able to understand and process the content covered. Adolescents who were found to have the most extensive trauma histories as assessed by the YTSI (e.g., physical/sexual abuse, neglect, witnessing community violence) and difficulty with emotional and behavioral regulation as reported by unit mental health workers were chosen for participation in the group. Initially, the group was composed of seven members aged 15 to 17 years old. They were of varied ethnic backgrounds (three African Americans, three Caucasians, one Latino), and they had different psychiatric diagnoses (psychosis, depression, anxiety, learning, disruptive behavior/conduct disorders, and substance use disorders). Their family histories differed (e.g., parental/sibling incarceration, raised by single parent, placed in foster care, have own children/girlfriends outside of detention), as did their reasons for incarceration (e.g., including status offenses, gang involvement, attempted murder, assault and battery, and armed robbery). All of the referred adolescents also reported having engaged in significant drug use, mostly marijuana, as well as drug selling prior to incarceration. Given that the group was voluntary, one of the Caucasian adolescents did not return after the first group session; he indicated that he was not interested in attending a therapy group. The remaining youths expressed interest in participating in the group. Finally, two of the adolescents (1 Caucasian and 1 African American) were released from detention mid-way through the group. Thus, the group finished with 4 remaining members.

Group Leaders

The group was co-led by two Caucasian therapists, one male and one female, in their late 20s. Both were advanced graduate students in a local clinical psychology doctoral program and had extensive graduate-level training in child/adolescent therapy as well as the effects of trauma exposure on psychological functioning. The co-leaders were provided with weekly supervision by a licensed psychologist and faculty member in their program (3rd author) who specialized in the treatment of trauma and also had extensive research and clinical experience with delinquent youth.

Group Format

The group was conducted for one-hour sessions, twice weekly, over a period of 12 weeks, totaling 24 sessions. Due to time constraints imposed by the facility, the entire duration of the original manual (i.e., 25 weeks with twice-weekly sessions) was not able to be implemented. The group was held on-site, in a detention center classroom. Security guards were sometimes stationed inside the classroom and other times outside the classroom door.

Manual Treatment Goals

The original manualized group intervention focused on three primary treatment goals. These were helping adolescents to 1) Manage the Moment (e.g., helping youths manage impulses, emotions, and acute distress more effectively), 2) Build Coping Strategies (e.g., helping youths strengthen their long-term ability to cope with the impact of traumatic life experiences and any associated difficulties), and 3) Enhance Resiliency (e.g., identifying youth’s current attempts to successfully manage the results of trauma, and enhancing those skills to take further steps at buffering extreme stress). A variety of specific skills were encompassed within each of the three broad treatment goals, all to assist the youths with more effectively managing the impact of trauma and resulting emotional and behavioral dysregulation.

Initial Sessions and the Immediate Roadblocks Encountered

The first one to two sessions were spent adhering relatively closely to the manual, which devoted two sessions to “Welcome and Introduction.” There were discussions and activities designed to orient members to the purpose of the group, and to develop group rules and rapport among participants and co-leaders. Almost immediately, the co-therapists realized that some changes were needed to enhance rapport establishment with this particular sample of youths, many of whom presented with significant symptoms consistent with conduct disorder and antisocial personality disorder. They were not interested in certain activities that they felt to be “hokey” or “pointless.” The following interaction illustrates this point:

• Co-Therapist #1 (CT1): So, have you guys ever been in any other groups like this before?

• Group Member #1 (GM1): Yeah, we all have. We have to do these things all the time.

• Co-Therapist #2 (CT2): Oh yeah? Have any of them ever been helpful?

• GM1: Nope. Mostly we just sit around while some adult tells us what we’re doing wrong. The worst is when they make us do these stupid activities. It’d be better if they’d just keep talking so at least I could get some sleep. CT1: What’s the worst activity you guys have ever done? What’s the activity that, if we did it, would convince you that we are complete idiots?

• GM2: Paper chains, man. One time we had to do f—ing paper chains so we could all learn how great we all are at everything or some s–t. That was probably the stupidest thing I’ve ever done in my entire f—ing life.

• GM1: Oh yeah, s–t man, I did that paper chain thing too! (Group members all start laughing)

In an effort to maintain the integrity of the manual while adapting the intervention to the needs of the particular group, the leaders proposed a more relationally authentic rapport-building activity. It entailed each group member identifying and verbalizing one good thing about the group member to their right; this activity was not only received well but spurred a great deal of discussion among the other group members. They all reported that none of them had heard directly how their peers positively perceived them.

As the manual existed at the time, the goal was to move past rapport building and developing group rules after session two in an effort to begin providing the group members with psychoeducation about the connection between trauma exposure and behavioral difficulties and how important it would be for their future to begin utilizing effective coping skills and tolerating distress effectively. However, it quickly became clear within two sessions of adhering to the manual that many of the adolescents were emotionally disengaged and were taking neither the content nor the co-therapists seriously. When the co-therapists paused the intervention in the middle of the third session to reassess what engagement activities were needed to proceed, a discussion was initiated by one group member. He focused on how the adolescents felt very “different” from their Caucasian, middle-class, professionally dressed, highly educated therapists. They did not think that the co-therapists could understand their lives or experiences, making the content being discussed irrelevant and impersonal. The therapists realized at this point that the structure of the manual during the initial sessions was not designed to address such large cultural discrepancies between therapists and group members. They also realized that the change/skills-orientation of the intervention, though theoretically well-grounded and clinically relevant, would not be effective, or even comprehensible, until a more authentic therapeutic alliance had been more firmly established between the co-therapists and the group members.

A Conceptual Reframing of “Maladaptive” Behavior Patterns

Although the therapists put substantial planning and effort into developing an authentic relationship with the group, they realized that they had to reassess their clinical strategy and develop an orthogonal approach to account for the youths’ extreme levels of skepticism and mistrust of the focus on behavioral change. Ultimately, the therapists determined that they needed to learn more about the youths’ lives, to understand what already worked, and to put aside their agenda as clinicians. They needed to learn from the youths what type of help was needed. Although the concept of developing a therapeutic alliance with clients is anything but novel in the field of mental health, few clinical frameworks incorporate a principle-driven, acceptance-oriented framework for doing so. There is little guidance about what types of stylistic strategies to use (i.e., “how”) in delivering acceptance-oriented interventions with highly treatment-resistant adolescents, and providing a clinical construct for framing treatment ambivalence or resistance. Broadly speaking, the stylistic techniques can be conceptualized as acceptance-oriented (as opposed to change-oriented) DBT strategies as outlined by Linehan (1993a). The primary set of acceptance-based strategies in DBT is validation strategies (see Linehan, 1997, for a comprehensive discussion of the definition and function of validation in psychotherapy). These strategies move beyond empathy-based interventions to the explicit acknowledgment of the inherent truth and validity of the client’s perspective based on the individual’s history and current circumstances.

Change-oriented strategies, such as problem identification and labelling and various strategies for enhancing commitment to behavioral change, are frequently employed in the early phases of treatment when operating from a DBT framework, especially with difficult to engage, multi-problem adolescents (see Miller, Rathus & Linehan, 2007). With incarcerated youths and other juvenile offender populations, heavier doses of acceptance with a de-emphasis on change strategies may need to be considered. This is important given the youths’ likely history of resisting others’ attempts to change their behavior and the invalidating experience of those attempts to “change” them. Linehan (1997) noted that validation-based approaches may be the main intervention approaches early in treatment, and certain clients may require substantially more validation than other, more change-based intervention strategies throughout treatment. Our assumption is that incarcerated youths require substantial levels of validation throughout treatment and (in DBT-language) during the “pretreatment” phase, in which clients’ commitment to the therapeutic process is being explored.

Finally, an irreverent communication style (Linehan, 1993a; Miller, Rathus, and Linehan 2007) proved to be invaluable to the co-therapists throughout the course of treatment with this group. It appeared to sufficiently build and maintain the authenticity of the therapeutic alliance. It should be noted that while both therapists intentionally used some irreverent communication strategies from the very beginning of the group, higher levels of therapeutic irreverence proved necessary. Additionally, it was their experience that an irreverent therapeutic style alone was not enough to overcome the need for increased acceptance-oriented strategies for the development of an authentic therapeutic alliance.

Calling a “Do-Over”: Therapeutic Re-Engagement through Acceptance-Based Strategies

The therapists attempted to validate the group members’ experiences by focusing the next two sessions on obtaining feedback from group members about what they would like to talk about and what was helpful or unhelpful about the intervention. The youths reported what the therapists had already sensed: Overall, they did not believe that the therapists could be trusted or that they could “really” understand them. Based on these two crucial sessions, the therapists eventually changed their approach to both the structure and content of the remaining sessions to one that was more client-centered. Primary interventions relied on in this phase were drawn from DBT: radical acceptance, radical genuineness, and significant (yet appropriate) therapist self-disclosure. A sample paraphrased interaction that occurred during these two sessions between co-therapists (CT) and group members (GM) is described below with specific validation strategies as outlined by Linehan (1993a) in italics:

• GM1: Talking about finding ways to “stay safe” doesn’t make any sense where we come from.

• CT1: Seriously? Tell us why (eliciting and reflecting thoughts and assumptions)

• GM1: On the streets, you can’t trust anybody, and you never know when the next thing is going to happen.

• GM2: That’s right. I was just walking down the street one day and watched my friend get shot in a drive-by a block away. I wanted to go help him, but I had to just turn and run because I knew I might be next.

• CT1: Wow… . that’s awful (Self-disclosing emotional reaction). Can you imagine that? (Question directed to CT2)

• CT2: Nope. I’ll tell you what, I sure never grew up like that (Respecting differing values).

• CT1: Neither did I (Respecting differing values). And if I did, I don’t think I’d believe any of this “staying safe” stuff either (Irreverently finding the “Kernel of Truth”).

• CT2: I know. I think it’s amazing you guys even survived all that (Providing reinforcement and reassurance). How did you do it (Focusing on the patient’s capabilities; Eliciting thoughts and assumptions)?

• GM1: You just have to be ready to fight, you know? You can’t escape it, so you just have to never look like you’re afraid, or someone’s gonna jump you, or worse. You can’t ever be weak.

A particularly salient topic during this phase of treatment became issues of race, class, and socioeconomic status. For instance, an entire session was devoted to both therapists’ and group members’ perceptions of each other. The therapists’ judicious use of self-disclosure about topics relevant to the youths’ lives, such as their own familial financial difficulties and personal challenges, were quite striking to group members. For example, during a discussion about differences in socioeconomic status between therapists and group members, it was discovered that a group member had, as did one of the therapists, grown up primarily in the New York City area. When the therapist disclosed that both her parents had been jazz musicians, he replied genuinely, “Oh man, you really were poor!” Balancing an acknowledgement of these areas of connection with discussions about the implications of true and unchangeable differences (such as the advantages of being Caucasian, having grown up in safer neighborhoods, and having been exposed to better schooling) resulted in a deepening of the therapeutic alliance. Interestingly, doing so also allowed group members to disclose their inaccurate assumptions about the therapists. For example, when asked to describe what he envisioned the therapists’ lives to be like, a group member stated: “All I know is that you’ve both gotta’ live in a house on a hill with a white picket fence, and probably drive a 2003 or 2004 Lexus.” The therapists gently disabused group members of this perception.

An Acceptance-Oriented Re-Application of the Manual

“Managing the Moment” and Revisiting the Development of Mindfulness

As a component of these “new” initial sessions focusing on both acceptance and awareness, the co-therapists asked the adolescents directly about the coping techniques they already used to disengage from intensely negative emotions or negative situations. All group members stated that listening to music served this purpose for them. The co-therapists began each group session by playing a song (either one brought by co-therapists or by group members). They asked group members to observe and describe, nonjudgmentally, various aspects of the music (e.g. beat, lyrics, melody, etc.) and its impact on their thoughts and feelings. Songs were usually requested by the adolescents and acquired, if necessary, by the co-therapists prior to the group meetings. Group members quickly became excited about having a forum to discuss their music, and as treatment progressed, the discussions about the emotional impact of the music deepened. This intervention was similar to the mindfulness exercises discussed in the Manual without describing it as such to the youth. Exercises using uncensored Hip-Hop and Rap songs requested by the youths, and discussing the music (being mindful to withhold any judgments of the content or nature of the songs), increased awareness and acceptance of emotions. The music served as highly validating components of the group for all members. Subsequent discussions were often allowed to extend much beyond the traditional three to five total minutes usually allotted to mindfulness activities. At times, the line between the mindfulness activity and the “rest” of the group session would become blurred. Over time, the therapists learned to how to balance the value of the discussion spurred by the mindfulness activity with the value of transitioning to another “coping skill.” They did this by waiting for a natural point of synergy between the two to arise, and using this “opening” to shift the discussion more naturally towards a change and skills-oriented path. When done optimally, this shift appeared to be imperceptible to the group members.

“Building Coping Strategies”: Revisited with Success

As the therapeutic alliance developed and deepened, the co-therapists began to introduce portions of the manualized approach that focused on “Building Coping Strategies.” The initial objective was to increase the youths’ awareness of the relationship between their past experiences and current thoughts, feelings, and actions. However, the co-therapists found that they needed first to be inherently validating of the youths’ perspectives and interpretations of their past experiences, before they could move to label or “teach” from a traditional psychoeducational framework. Below is a paraphrased interaction that occurred during this portion of the treatment, followed by the specific type of DBT validation strategy as defined by Linehan (1993a):

• CT1: So, how did any of you know that people in your family cared about you?

• GM1: The way I knew my mom loved me was when she put me in my place. I remember one time, I did something pretty bad, and she beat me over the head with our answering machine. She was chasing me all over the house with that thing (laughing). She beat me pretty bad, too. I think she even broke it, she hit me so hard (group members laughing).

• CT2: You know, I wouldn’t have thought about that being a way you’d know your mom loves you. That’s a totally new thing for me to find out about (Being awake and nonjudgmental to client’s experience).

• GM1: Whaddya’ mean?

• CT2: Well, where I came from, that kind of thing would be thought of as bad to do to kids. That might even be called physical abuse (Discriminating facts from interpretations). What do you guys think about that (Eliciting thoughts and assumptions; Providing opportunities for emotional expression)?

• GM2: Naw, you don’t get it. What’s really bad is when [your parents] don’t even care what the hell you do. Or when they tell you you’re stupid or worthless or that you never should have been born.

• GM1: Yeah, that’s for sure. [Parents] can beat you all they want, but saying that kind of stuff is what’s the hardest to take (group agreement).

• CT2: That actually makes a lot of sense to me (Finding the “Kernel of Truth”; Communicating the validity of emotions). That would really be awful. (Reading emotions, Communicating the validity of emotions).

Had the therapists challenged the youths’ initial conceptualization of parental beatings as love more directly, the group may have missed an opportunity to discuss the more emotionally painful issue of being invalidated by parents through insults or neglect. Moreover, the group members were then given enough leeway to validate one another on this important issue. The therapists did not validate the invalid, that is, they did not condone physical abuse. Instead, they chose to highlight and validate a larger humanistic truth for this group of adolescent males: Physical abuse can be both a signal of parental “love,” and much less invalidating than the emotional abuse and neglect that they have endured.

From the therapists’ perspective, it became clear that frequent use of validation and acceptance-oriented strategies was beginning to foster increasingly more open and non-defensive discussions by the group participants. This openness led to a willingness by the youths to participate in more “psychoeducational” discussions evaluating the pros and cons of various behaviors, such as fighting, selling drugs, and gang-related activities.

A Group-Initiated Shift Towards a Change Orientation

Approximately midway through the course of treatment (session 12 or so), substantial progress had been made concerning the development of the therapeutic relationship between the therapists and group members. The therapists had genuinely learned a substantial amount about the day-to-day experiences of group members, both while detained and “at home” in their families and communities. As discussed above, this had occurred through the predominant use of a variety of validation and acceptance-based strategies drawn from a DBT intervention framework. At this point, a notable shift began to occur, dictated exclusively by the group members rather than the clinicians. Specifically, they began to acknowledge that their past behavioral decisions had not always led to successful or positive outcomes but instead were often quite problematic. Additionally, they admitted without prompting that many experiences in their lives were, in fact, things they would never like to experience again. These types of acknowledgments would not have been possible in the early stages of treatment. As sessions continued, the adolescents were better able both to acknowledge the negative long-term outcomes of many of their maladaptive behaviors and creatively to generate more adaptive behavioral and cognitive alternatives (e.g., staying away from specific areas of their neighborhood, engaging in more pleasurable activities, attempting to consider pros and cons of behaviors in the moment). Opportunities began to arise for the clinicians to begin safely utilizing more of the psychoeducational, skill-building, and change-oriented strategies outlined in the manual. Because of the limited remaining course of treatment (approximately eight weeks), however, certain core concepts were retained while others were dropped. Core concepts presented and discussed during this middle phase of treatment from the manual were: 1) The impact of chronic stress and traumatic experiences on the body and mind, or “Unfinished Emotional Business;” 2) Concepts representing the balance between using logic and emotion in the decision-making process (i.e., “Reasonable Mind,” “Emotional Mind,” and “Wise Mind”); and 3) Developing the skills necessary for identifying and managing intense emotions (i.e., “Crisis Survival Skills”). These topics were always presented (a) in the context of the youths’ past and current difficult life histories, and (b) with the tone of clinician curiosity and ambivalence about whether the “information” being presented was at all relevant to the youths. It had the effect of strategically placing the therapists in a collaborative and, at times, deferential relationship with group members. The group had the authority to determine whether the information might be useful in their lives. Examples used to frame these concepts were rarely provided by the therapists but were elicited from the youths whenever possible to ensure that the discussion context remained ecologically valid and relevant to group members. While the focus shifted to problem-solving, skill-building, and general change-oriented frameworks, a much higher proportion of DBT-based irreverence, validation, and acceptance-based interventions continued to be used. This was more than was suggested in the original manual or than might be otherwise thought necessary by clinicians unaccustomed to treating adolescents who met criteria for conduct disorder and who had initial nonverbal presentations as unemotional and relationally disconnected. A paraphrased interaction during this phase highlights the challenge for the therapists to balance acceptance and change-oriented strategies with this population of youths even once therapeutic rapport was established. It was especially difficult when morally complex and psychologically intense behavioral content were discussed:

• GM4: I could have done a lot more bad things than I already have.

• CT1: Like what? (Acceptance-based Intervention: responsive, non-judgmental)

• GM4: One time my girlfriend cheated on me, and I went back and got my gun from under the porch. I found the guy down the block and put the gun to his head, told him he was gonna die. I pulled the trigger and everything, but it didn’t go off… . been in the dirt for too long I guess. After that, I just beat him up instead.

• CT2: Wow, that’s intense (acceptance-based intervention: Validation of experience, but clinician unsure whether it is safe yet to move to a change-based strategy, so he seeks out more information from acceptance-based stance) … Thinking back, are you glad you didn’t shoot him?

• GM4: Yeah, guess I got lucky. I knew the whole time I shouldn’t kill him, but I was just so f—ing pissed off and hurt I guess too that she did that to me.

• CT1: So you wanted to make a different decision, but you were so angry it was hard to do. (Acceptance-based intervention: Paraphrasing client’s experience; clarification of emotional and behavioral dysregulation; highlighting the discrepancy between the youth’s ideal behavior and actual behavior)

• GM4: Yeah, real hard, man. Looking back, I wish I never pulled the trigger. It’s like, man, am I really someone that would kill a nigga just cause of a girl like that? (GM4 acknowledges regret and wish that behavior had been different, so change-based intervention is now possible)

• CT1: It’s really tough when we feel out of control like that, right (Acceptance-based intervention: Mind-reading client’s emotional reaction)? (To group members): Leads pretty quick to an “emotion mind” decision just like GM4 described (clinician preparing to transition to change-based strategy). What else could have done to try and manage his anger better in that situation (Change-based intervention)?

Final Phase: “Enhancing Resiliency” Revisited

Over the last several sessions of the time-limited treatment, group content began to focus more on the development of, and reflection upon, the interpersonal relationships developed between group members and co-therapists. Treatment goals during this final phase involved: 1) helping group members learn how to develop and maintain positive relationships both while detained and upon release, 2) highlighting areas of mastery within themselves in order to increase self-efficacy, and 3) identifying (in as much detail as possible) their plans for the future and how to achieve them. To do so, several of the original modules in the manual targeting each of these clinical objectives were implemented relatively unaltered.

It was particularly useful to have the youth reflect on the development of their relationships with other group members and the co-therapists. Issues discussed included how to learn to trust others, how to judge others’ intentions and integrity, how much to open up to others, and how to communicate one’s needs and feelings. Specific people to target for healthy relationships while in detention were identified, and future relationship planning was discussed to assist the youth with interpersonal goals upon release. These discussions were frequently frustrating for both the therapists and group members, as together they had to face the fact that they had very few people in their lives upon whom they could depend for support and guidance. Additionally, gang-involved group members wrestled with how they could safely minimize their involvement in their gang’s activities. For two group members, death was a very real possibility should they be perceived at attempting to “quit” their gang. The group openly discussed ways that members could stay “safely” gang-involved while minimizing their risks for being forced to commit serious and dangerous crimes. It is clinically noteworthy that the actions for which these youths were frequently criticized and punished (i.e., lying, manipulating, deceiving, and misleading others) can be adaptive and potentially lifesaving.

Given that most of the group members had few life experiences of feeling efficacious or self-valuing, helping these members identify areas of mastery to increase self-efficacy proved to be quite challenging. One youth painfully discussed the ways teachers had reportedly called him names, such as “stupid,” “retarded,” “worthless,” and “a waste to society.” Validation of this youth’s experience became complicated because he clearly believed that these teachers were correct in their reported assessment of his lack of educational potential. As a result, the co-therapists needed to frequently present objective evidence to this youth (e.g., high levels of authentic praise for an insightful comment) to counteract the cumulative effects of these educational experiences.

Another hurdle related to improving these youths’ low self-efficacy was their extreme ambivalence about creative self-expression for fear of being rejected by the co-therapists and other group members. For instance, two of the group members were encouraged to bring in their artistic work, such as rap lyrics and drawings, for group discussion. This was clearly considered an extremely emotionally-risky action for them; in fact, many of the youths resisted doing this for several weeks. When they shared their art forms with the group, each member demonstrated strikingly anxious nonverbal behavior. Each appeared extremely surprised and relieved when his work was received in a unanimously positive manner by the cotherapists’ and other group members. The unfolding of this process appeared authentically validating and helped to build both self-efficacy and group cohesion. Particularly in this final phase of treatment, the co-therapists attempted to strike a fine balance between DBT-oriented reciprocal and irreverent communication strategies as a means for minimizing the obvious anxiety associated with such risky self-expression. A brief, paraphrased excerpt of one validating interaction is described below (labels of the example stylistic strategies used to enhance rapport and increase resiliency are included):

• CT1: (Clinician looking at horror-movie style clown face drawing, with a sword through his head, one eye all black, the other eye clear, etc.) Wow, you have really got some talent going on here (Responsiveness and Warm engagement).

• GM3: No way, you’re just bulls—ting me.

• CT2: No bulls–t here, sir (Reframing in an unorthodox manner). There’s no way I could draw like that. Look at all the details – you really took your time with this, and obviously know what you’re doing (Expressing impotence and omnipotence).

• GM3: This is why all my teachers said I was a worthless human being. All I could think about in school was drawing this stuff, so that’s all I did. Everyone said [drawing like this all the time] proved I was stupid, because it showed I couldn’t learn anything. (Hesitates)… . What do you like about it?

• CT2: (Thinks for a minute while staring at the picture): The eyes – the eyes are my favorite part of the whole drawing. It seems like you’re really trying to say something with the eyes (Responsiveness, Genuineness; Oscillating intensity and using silence).

• GM3: Yeah, the eyes… . that’s my favorite part too. I worked real hard on the eyes.

The Final Session

The therapists took great care preparing for the final group session. They carefully structured it to maximize the functional and explicit validation of the youths as individuals, as a group and with particular regard to their progress throughout the 12-week treatment. In the first half of the session, the therapists gave the adolescents feedback as a group. To emphasize the interpersonal aspects of the treatment and to highlight the youths’ potential for positive impact on others, feedback focused not on the adolescents’ performance, but on the impact that each group member had made on each of the co-therapists both personally and professionally. This feedback was received extremely well by the group members, who appeared highly surprised that they could have such an effect. Consistent with the Manual’s recommendation, group members were given signed “Certificates of Completion.” All four youths completing the group reported surprise and appreciation for this and reported that it was the first time any of them had ever received a certificate or award of any kind.

During the second portion of the session, the co-therapists spent 15 minutes with each youth separately. Each youth was presented with a small gift (such as themed magazines, a specific book, or voice recorder for a youth with a talent for rapping) based on his interests discovered through the group process, and individualized cards from each therapist. The cards described in detail the therapists’ appreciation, view of the youths’ growth over the course of treatment, and strengths (and challenges) to be anticipated as they move forward in their lives. This portion of the session was particularly moving for both therapists. The youths gave intimate and sometimes striking feedback, such as “You’ve helped me to feel again,” and “You’re the first people to never make me feel like I’m stupid.”

Clinical Implications and Future Directions

As members of the treatment group poignantly reminded us, authentically engaging youths with a history of repeated, pervasive trauma and conduct disorder on a human level is essential, albeit often challenging. Given the past behaviors, sometimes intimidating interpersonal presentations, and profound distrust of this group, we found that engagement is greatly facilitated by using acceptance-oriented strategies (such as those in DBT) to maintain high clinical attunement to the therapeutic alliance throughout treatment. We posit that these interventions are necessary, regardless of the specific clinical framework or therapeutic modality being used.

Although authentic human engagement was a necessary component of this treatment course, this factor alone was not sufficient to explain the clinical movement seen and described in this particular clinical case example. Skills-based, change-oriented approaches were also necessary and were explicitly and spontaneously requested by the youths once the alliance had been established. The youths with whom we worked presented with substantial skills deficits across a variety of psychosocial and behavioral domains, such as emotion dysregulation, reduced sense of identity and life meaning, behavioral impulsivity, and significant prosocial skills deficits, which were consistent with a complex or developmental trauma framework. Without implementing skills-based treatment components, these youths would have developed no new psychological or behavioral tools for managing their extremely challenging lives both during and after detention.

Although many evidence-based treatments inherently focus on change, very few of these treatment manuals have actually elaborated on how critical acceptance and validation strategies are to the facilitation of such change. In the last two decades, more empirically-supported treatments have begun to formally acknowledge the importance of balancing change with acceptance-based strategies, including Dialectical Behavior Therapy (Linehan, 1993a), Motivational Interviewing (Miller and Rollnick, 2012), and Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 2011). We encourage clinical researchers, especially those who work with multi-problem clients and adolescents, to continue to attend to and refine acceptance-based strategies for their use in all stages of treatment.

Finally, research identifying effective interventions for behaviorally disordered youths who have complex PTSD and are in restricted settings is greatly needed. We posit that one possible starting point for such research should be adaptations of existing, empirically informed or empirically-supported treatments, such as SPARCS and DBT. We recommend the incorporation of principle-driven guidelines and relationally based clinical markers for the establishment of a strong working therapeutic alliance prior to moving into primarily change and skills-oriented treatment phases of these existing interventions. However, other creative approaches should also be explored.

A member of the juvenile detention staff reported to the co-therapists that the group member who stated, “you helped me feel again,” was stabbed in the chest at a party and nearly killed just a few weeks after being discharged from juvenile detention. Solutions to the problem of how to effect meaningful change with youths such as the young men described in this paper cannot arrive fast enough. Without purposeful and urgent attention, young men like those described in this paper, who are some of the most marginalized, traumatized, and socially costly youths in our country, will remain inadequately treated and will have little hope of meaningful re-entry into mainstream society.