Treatment Acceptability Study of Walking The Middle Path, a New DBT Skills Module for Adolescents and their Families

Introduction

Outcome research has repeatedly indicated that dialectical behavior therapy (DBT) is effective in improving the quality of life and reducing self-harm among individuals with borderline personality disorder (cf., Koerner & Dimeff, 2007; Robins & Chapman, 2004). Miller and Rathus (Miller et al., 1997; Miller, Rathus, & Linehan, 2007) developed a modified version of DBT for adolescents who were suicidal and had multiple problems. Dialectical behavior therapy for adolescents targets teens who exhibit chronic emotional dysregulation and a pattern of impulsive and/or risky behaviors.

Miller’s and Rathus’ modifications maintain the theoretical and structural underpinnings of DBT, while incorporating caregivers in the skill groups, add family therapy sessions, simplify skills hand-outs sheets with teen-relevant examples, and offer phone consultation to parents (Miller et al., 1997). As the use of DBT with adolescents has increased, so has evidence of the treatment’s effectiveness with this population (e.g., Goldstein, Axelson, Birmaher, Brent, 2007; Mehlum, Tormoen, Ramberg, et al., 2014; Rathus & Miller, 2002).

Initial work with DBT in adolescent populations led to the observation that adolescent clients and their caregivers exhibit unique dialectical dilemmas (Rathus & Miller, 2000). In standard DBT, dialectical dilemmas are conceptualized as behavioral patterns (typical of suicidal and BPD patients) wherein an individual shifts between polarized positions (Linehan, 1993). Alternating between extreme behaviors represents an attempt to correct intense emotional dysregulation. However, because these extreme behaviors tend instead to underregulate or overregulate emotions, they can be understood as dialectical failures.

The adolescent-family specific dialectical dilemmas formulated by Rathus and Miller (2000) are behavioral extremes frequently experienced by parents of suicidal, multi-problem adolescents, as well as by the teens themselves. While Linehan’s (1993) dialectical dilemmas are applicable to this population, Rathus and Miller’s dilemmas highlight the unique interaction patterns of troubled adolescents and their families. The adolescent-family dialectical dilemmas are 1) excessive leniency versus authoritarian control, 2) pathologizing normative behaviors versus normalizing pathological behaviors, and 3) fostering dependence versus forcing autonomy.

To target the behavioral patterns related to these dialectical dilemmas, Rathus and Miller (2000) developed a fifth skills training module, walking the middle path. In addition to teaching families about the adolescent-family specific dialectical dilemmas, walking the middle path reviews the concept of dialectics, which is both the philosophical basis of DBT and a component of its core intervention strategies. Dialectics helps families integrate multiple perspectives, think in a less black-and-white fashion, and generate balanced, rather than extreme, solutions to the adolescent-family dilemmas. Walking the middle path also highlights two skill areas that comprise the core dialectic of DBT: acceptance and change (Miller, Rathus, and Linehan, 2007). Acceptance is targeted through validation skills, while change is targeted through behavioral modification skills.

Validation is a central component of standard DBT; Linehan’s (1993) biosocial theory of borderline personality disorder suggests that individuals with BPD are brought up in pervasively invalidating environments. Linehan (1993) defined the invalidating environment as one in which “Communication of private experiences is met by erratic, inappropriate, and extreme responses … . The expression of private experiences is not validated; instead, it is often punished, and/or trivialized” (p. 49). Miller, Rathus, & Linehan (2007) have highlighted that invaliding environments for teens may include (but are not limited to) schools (i.e. teachers, administrators), peers, coaches, therapists, and family members (i.e,. those with whom they live as well as other relatives).When reared in an invalidating environment, an emotionally vulnerable child may come to doubt her personal understanding of her experiences and learn that her feelings are unacceptable to others, while failing to learn strategies to manage emotions and solve problems. Invalidation is central to the development of problematic behaviors and chronic emotional dysregulation, in part because it teaches a child that only extreme behaviors and emotions provoke a desired response from the environment.

It stands to reason that suicidal, multi-problem, emotionally dysregulated adolescents will also frequently be products of invalidating environments. Indeed, research has indicated that adolescents who perceive their parents as uncaring or affectively unresponsive are at an increased risk for suicidal ideation and behavior (King, Segal, Naylor, & Evans, 1993; Adam, Keller, West, Larose, & Goszer, 1994). One difficulty in addressing the sequelae of chronic invalidation in adolescent populations, in contrast to adult patients, is that the adolescent patients are typically still residing in the invalidating family environments (Woodberry, Miller, Glinski, Indik, & Mitchell, 2002). Thus, to reduce the cycle of invalidation that occurs in some of these families it is necessary to target the environment itself by including families in skills training.

Walking the middle path also focuses on behavioral change strategies. The specific topics include positive reinforcement, negative reinforcement, shaping, extinction, and punishment. In standard DBT, these learning principles are integral to the treatment; the therapist reinforces target-relevant adaptive behaviors in session, and uses chain analysis, a complex, detailed functional analysis, to help both patient and therapist understand what factors trigger and maintain maladaptive behaviors (Linehan, 1993). By teaching the entire family behavioral modification techniques such as principals of reinforcement and shaping, in addition to offering as-needed family sessions, there is a greater likelihood of the adolescent and the parent generalizing adaptive skills outside of the therapy office.

An increasing number of families have taken part in walking the middle path, and is reflected in the growing research that uses Miller’s, Rathus’s, and Linehan’s (2007) protocol. These studies suggest that use of this protocol with adolescents exhibiting suicidality, BPD features, and/or other psychiatric disorders is associated with a reduction in behavioral problems, self-injury, and emotional dysregulation (see Groves et al., for review; Mehlum et al., 2014). Despite the increase in its use, the specific contribution of walking the middle path has not been examined.

The current investigation serves as a first step towards assessing the impact of walking the middle path by evaluating its acceptability. The concept of treatment acceptability grew out of Kazdin’s (1977) and Wolf’s (1978) work on social validity, which held that in addition to efficacy, new treatments must also be examined in terms of social significance, appropriateness, and relevance. Treatment acceptability is a vital component of treatment evaluation; as Wolf (1978) notes, “if an intervention is effective but disliked, consumers will be unlikely to use it.”

There has been little exploration of the acceptability of adolescent DBT. In a modified DBT program for adolescents with eating disorders, Schneider et al. (2010) found high ratings of consumer satisfaction, with a strong correlation between ratings of adolescent patients and their parents. Goldstein, Alexson, Birmaher, and Brent (2007) included a treatment satisfaction questionnaire in their research on adolescent DBT that yielded high ratings of acceptability. Cooney, Davis, Thompson, et al., (2012, November) assessed the acceptability of adolescent DBT to gauge the feasibility of larger scale randomized control trials. Results indicated that treatment completion and attendance rates were higher for adolescents in DBT as compared to usual treatment, and that families found DBT acceptable.

The aim of this study was to assess acceptability and perceived helpfulness of walking the middle path to adolescents and parents, in order to support a rationale for further evaluation of the module’s effectiveness. The study aimed also to illuminate which aspects of middle path participants found helpful; to this end a qualitative analysis was performed regarding participants’ evaluations of the module.

Method

Participants

Participants (N=50) were recruited from three New York DBT programs—two private practices in Long Island and Westchester and an outpatient adolescent clinic at a hospital in the Bronx. Each site offered comprehensive DBT, used Miller, Rathus and Linehan’s (2007) DBT multi-family skills training protocol, and included walking the middle path in the skills training. Participants included adolescent patients and parents/caregivers who took part in skills training; all adolescent clients had weekly individual DBT sessions. To receive treatment, clients at the two private practices needed to exhibit at least three DSM-IV criteria for BPD. At the hospital site, clients also needed to have one suicide attempt or incident of non-suicidal self-injury in the six months prior to treatment. Exclusion criteria at each site included psychotic disorder or primary substance abuse diagnosis. Table 1 lists demographic characteristics. All participants identified as Non-Hispanic White or Hispanic; all Hispanic participants were from the hospital site.

Measures

Treatment Acceptability Scale

Questions on the Treatment Acceptability Scale scale (TAS) were drawn from the Treatment Evaluation Inventory-Short Form ([TEI-SF] Kelley, Heffer, Gresham, & Elliott, 1989), a condensed version of Kazdin’s (1980) Treatment Evaluation Inventory (TEI). The TEI is one of the most commonly used measures of treatment acceptability (Gage & Wilson, 2000). The TEI–SF is shorter and uses simpler language than the TEI (Finn & Sladesczek, 2001). The TEI-SF has been found to be valid and internally consistent (coefficient α=.85). As the TEI-SF was originally designed to assess parents’ acceptance of interventions for children, questions were modified for the current study, with the words “walking the middle path” replacing “intervention.” Questions were also drawn from the Child and Adolescent Mental Health Satisfaction Scale (CAMHSSS;

Ayton, Mooney, Sillifant, Powls & Rasool, 2007). The CAMHSSS is an internally consistent and reliable measure of treatment satisfaction (Cohen’s kappa of items range between .61–.80). Additional TAS items, devised by the investigators, asked participants to rate the middle path module on its relevance, on how much they believed it would promote behavioral change in their child or parent, and about how glad they were that they took part in it.

All questions on the TAS were rewritten to be at a Flesch-Kincaid fifth-grade reading level. Each item was rated on a five-point Likert scale: Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree. The scores of each item jointly yielded a single acceptability score, the magnitude of which represents the participant’s rating of the acceptability of the module.

DBT Skills Rating Scale for Adolescents

Rathus & Miller (1995) developed the DBT Skills Rating Scale for Adolescents (DBT-SRS) in order to assess perceived helpfulness of DBT skills across all modules. Subjective ratings of helpfulness for individual skills are assessed on a five—point Likert scale ranging from “not at all helpful” to “extremely helpful.” Participants in the current study were administered a revised version of the DBT-SRS, which included skills taught in the walking the middle path module. The psychometric properties of the DBT-SRS are unknown.

Open-Ended Assessment

To gather detailed information about which aspects of middle path informed participants’evaluation of the module, open-ended questions were administered, including: “What did you like most about walking the middle path and why?” and “In what way do you think middle path could help you and your family?”

Procedures

A demographic form, the Treatment Acceptability Scale, was administered and the open-ended assessment following completion of the middle path module (the modules last for four to five weeks, with groups meeting weekly for two hours). Once participants completed all five skills training modules, they completed the DBT-SRS. All participants in the current study completed the TAS and the qualitative assessment, though a minority (N = 13) left treatment prior to completing all skills training modules, or declined further participation in the study after completing the initial assessments, therefore, they did not complete the DBT-SRS. The skills trainers at each site included at least one doctoral-level clinician with specialized training in DBT. Cofacilitators were either doctoral-level clinicians or pre-doctoral trainees. All group leaders participated in DBT consultation team meetings at their respective sites.

Treatment Fidelity

Data regarding treatment adherence was collected from a subsample of sessions—those conducted at the Long Island site. Group leader self-report adherence measures (i.e., checklists based on the manual’s outlined content) indicated that across two middle path module presentations, group leaders covered the material as outlined in the mid dle path protocol with 100% accuracy during one presentation of the module, and with 88% accuracy on the second. Additionally, one of the treatment developers was a group leader at the Long Island site. While data regarding treatment adherence was not obtained from the Bronx or Westchester sites, at both sites the group leaders were supervised by a treatment developer of the middle path module.

Qualitative Analysis

Two coders, who had received training in DBT, reviewed de-identified data from the open-ended assessments. Each coder independently made notes on the themes and concepts that emerged from the data, following a technique derived from Strauss and Corbin (1990). Together, the two coders then created a coding manual that broke larger concepts into smaller, definable categories. Coders focused on the general impact of the module, as well as specific content participants identified. Frequency of specific skill references was also recorded (Table 2).

The two coders independently sorted responses into the devised categories. Intercoder reliability was calculated for each category using Cohen’s Kappa (Cohen, 1960). Kappa values for the categories ranged from .47 to 1, with only two of the 15 categories obtaining Kappa values of less than .60. Generally, inte-coder agreement was high, likely due to the structured nature of the questions, which allowed responses to be classified with little inference. Discrepancies in categorization were resolved through discussion between coders, and the consensus classification was used.

Results

Descriptive statistics were calculated for each item on the TAS, and an overall acceptability score was derived from the mean scores of the nine items (see Table 3). The overall acceptability score (4.23) indicated that the module was found to be acceptable; participants agreed or strongly agreed that the module was useful, interesting, and applicable. A two-sample independent group t-test was performed; no significant differences in acceptability ratings of adolescent and parent participants were found.

Descriptive statistics were calculated for each skill on the DBT-SRS, and items were ranked in order of perceived helpfulness (Table 4). For adolescents, the top five most highly rated skills were validation, reinforcement, wise mind, dialectical thinking, and acting effectively. For adults, the top rated skills were validation, wise mind, reinforcement, dialectical thinking, and acting effectively. For both groups, middle path skills comprised three of the top five most highly rated skills. An independent sample t-test was conducted on parent and adolescent ratings of perceived helpfulness of middle path skills; no significant differences between adolescent and parent ratings were found.

Forty-one responses were coded for the question, “What did you like most about walking the middle path and why?” Thirty-one were coded for the question “In what way do you think Middle Path could help you and your family?” Tables 5 and 6 show the breakdown of frequency of responses in each category, kappa ratings, and sample responses.

Discussion

On the Treatment Acceptability Scale, eight of the nine items received average ratings ranging from “agreed” to “strongly agreed,” indicating that middle path was regarded by participants as helpful, interesting, and relevant. Additionally, three of the five DBT skills rated most highly (of 27 total skills taught) in perceived helpfulness were from the middle path module. Overall, the middle path skill of validation was rated by both parents and adolescents as the most helpful.

Both parents and adolescents identified reducing conflict and making relationships “closer” and “warmer” as benefits of practicing validation. The following participant quotes are representative of the recurring theme that validation improved families’ functioning:

These responses support the sentiments of Miller et al. (2002): “It has been our experience that teaching families how to validate one another is the most crucial interpersonal skill for improving their relationships.”

(p. 578).

According to Fruzzetti and Schenk (2008), validation has a soothing impact, reducing emotional dysregulation while invalidation escalates arousal. They note that when individuals are emotionally aroused, they demonstrate reduced cognitive capacity, and self-awareness and stability of self-image is jeopardized. As a result, an invalidated individual has difficulty with accurate self-expression, and is less likely to communicate effectively and be understood by others. The result is a continued cycle of invalidation that further increases emotional arousal. Inevitably, this heightened arousal leads to interpersonal conflict. Another outcome is engagement in dysfunctional behaviors, such as self-harm, to attempt to modulate one’s emotions (a hallmark pattern of self-harming adolescents). In contrast, when family members communicate understanding and endorse the legitimacy of another family member’s feelings and experiences (validation), emotional arousal is reduced. Self-expression becomes more accurate, increasing the likelihood the individual will receive further validation. The intensity of conflict is reduced, as are emotional dysregulation and maladaptive behaviors. Individuals feel soothed, and relationships become less averse. This process was summed up simply and eloquently by one participant who stated, “ Validation … allows empathy, and can shift energy from resistance to cooperation and understanding. It opens up alternatives to conflict.”

In addition to validation, the most highly rated of all DBT skills on the DBT-SRS were from the middle path and mindfulness modules. One change-oriented skill (reinforcement) was ranked in the top five. The desirability of learning to use positive motivators to change behaviors of self and others is not surprising given the frequent use of coercive and punishing strategies to change behaviors in families entering treatment (cf., Barkley, Edwards, & Robin, 1999).

Three other skills focused on acceptance of self and of others (validation) and of reality as is (acting effectively, wise mind). These skill rankings support Miller’s, Wyman’s, Huppert’s, Glassman’s and Rathus’s (2000) findings that adolescents rated acceptance-oriented skills as more helpful than change-oriented skills in DBT-A. Miller and colleagues (2000) suggested that the acceptance skills were new to the repertoires of suicidal adolescents, who tend to avoid painful experiences and emotional states. The qualitative data from the present study seem to support this notion; many respondents discussed how validation in particular was a new concept to them: “And validation!! How helpful was this piece … I just didn’t know … didn’t realize.” Interestingly, the novelty of validation as a behavioral skill was commented on not only by adolescent participants, but also by parents as well, as demonstrated by this quote from a mother: “Sometimes I didn’t even know how invalidating and judgmental my responses to my daughter were. This module gave me an awareness! To catch myself and then gave me the very tools to use to change.”

The current study also replicated Miller and colleagues’ (2000) findings that even the lowest-ranked DBT skills received mean ratings between neutral and helpful; no skills received ratings in the somewhat unhelpful or very unhelpful range. As the authors of the previous study (2000) caution, the ratings of helpfulness may be subject to demand characteristics. In the current study, attempts were made to reduce demand characteristics by having the primary investigator, rather than the group leader, administer assessments when possible.

Limitations of the Current Study

One methodological issue common to studies of treatment acceptability is that ratings were only collected for participants who completed middle path. Individuals who left treatment early may have had different experiences with middle path or skills training in general. An additional limitation is that this study evaluated the module’s acceptability to participants; researchers have noted that it is difficult to determine whether subjective evaluations of acceptability correspond with actual behavior (Hawkins, 1991). The degree to which approving of middle path skills led to increased skill use and if skill use led to improvements in participants’ lives are unknown. Qualitative data does lend support to the notion that participating in middle path led to improved family functioning; however, a systematic evaluation of post-middle path outcomes is required to draw firm conclusions about the behavioral impact of the module.

Treatment adherence was assessed at only one of the three sites (Long Island), and was assessed by facilitator self-report rather than by independent observation. However, 78% of participants were from this site, and the co-leader of this skills-training group was a developer of the middle path module.

Finally, generalizability was limited because the participant sample was predominately white and from an upper-middle class economic background. The small number of minority participants (who received treatment at an inner-city hospital) makes it difficult to draw conclusions about what, if any, role ethnicity and socio-economic status play in how acceptable a participant finds middle path.

Future Research and Clinical Implications

Despite these limitations, the current study provides preliminary support for the use of middle path as part of Adolescent DBT skills training. Pending the findings of upcoming randomized controlled trials on Adolescent DBT by Marsha Linehan and colleagues (Collaborative Adolescent Research on Emotions and Suicide [CARES]) and by Mehlum and colleagues (Mehlum et al., 2014), dismantling studies could examine the specific contribution of middle path to the efficacy of DBT for adolescents. In assessing the contribution of middle path, one avenue of inquiry suggested by the current study is an examination of the relationship between ratings of helpfulness and functional improvements. Miller and colleagues (2000) have examined the relationship between adolescents’ ratings of skill helpfulness and improvement in corresponding life problem areas. Similarly, Neascui, Rizvi, and Linehan (2010) have examined the use of standard DBT skills as a mediator of treatment outcomes. Both studies suggest that perceptions of skill helpfulness and skill use correlate with or mediate improvements in functioning.

The current study raises the question of whether perceived improvement in family functioning attributed to middle path corresponds to a reduction in adolescent self-harm and other dysfunctional behaviors. Family functioning is considered a vital treatment target in DBT for adolescents because problematic family interactions have been demonstrated to heighten suicidal risk (see Woodberry, et al., 2002, for review).

Findings regarding the value participants placed on validation can inform the work of clinicians who work with families, in- and outside of DBT. For families who are highly conflictual and in which negative emotional arousal is pervasive, teaching the skill of validation may be a powerful tool for improving family functioning. Findings of the current study support the inclusion of middle path skills in DBT with adolescents. While results are preliminary and derived from nonexperimental research, the high perceived helpfulness ratings of middle path skills suggests that participants found them to be of unique value and utility.