Assessment of Parents, Couples, and Families in Dialectical Behavior Therapy

Journal Pre-proof Assessment of Parents, Couples, and Families in Dialectical Behavior Therapy

Alan E. Fruzzetti, Luciana G. Payne PII:

S1077-7229(19)30108-7

DOI:

https://doi.org/10.1016/j.cbpra.2019.10.006

Reference:

CBPRA 790

To appear in:

Cognitive and Behavioral Practice

Received date:

1 February 2018

Revised date:

21 August 2019

Accepted date:

26 October 2019

Please cite this article as: A.E. Fruzzetti and L.G. Payne, Assessment of Parents, Couples, and Families in Dialectical Behavior Therapy, Cognitive and Behavioral Practice(2020), https://doi.org/10.1016/j.cbpra.2019.10.006

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© 2020 Published by Elsevier.

Journal Parent, Pre-proof Couple & Family Assessment in DBT Assessment of Parents, Couples, and Families in Dialectical Behavior Therapy Alan E. Fruzzetti & Luciana G. Payne McLean Hospital & Harvard Medical School

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Contact: Alan E. Fruzzetti McLean Hospital 115 Mill Street Belmont, MA 02478 [email protected]

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Draft in review: Please do not quote or cite without permission

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Abstract Family intervention in Dialectical Behavior Therapy (DBT) is a core part of multiple required functions of DBT, providing opportunities for skill training (including relationshipspecific skills that are not covered in individual DBT), skill generalization, and direct

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intervention into the social and family environment. In order to intervene with parents, partners

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and other family members efficiently and effectively, therapists must first conduct a careful

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assessment. The core relationship transaction of emotion vulnerability/dysregulation and inaccurate expression leading to invalidating responses (and vice versa) is highlighted, as are the

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treatment targets in DBT with families, which inform assessment targets. Then, two core

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assessment procedures are explored, with clinical examples: (a) conducting “double chain”

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analyses, demonstrating how one person’s social or relationship responses affect the other’s emotional arousal (and vice versa); and (b) direct behavior observation of family interactions,

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which allow treatment targets to be identified efficiently. These two assessment strategies may

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also be combined. Implications for family interventions are discussed.

Keywords: Dialectical Behavior Therapy; behavioral assessment; family assessment; couple assessment; chain analysis; double chain analysis; family intervention; transactional model

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Despite our current zeitgeist of “brain” disorders and “individual psychopathology,” research tells us clearly that individual psychological problems and disorders are multiplydetermined, and primarily occur in a relational context, affected in no small way by those relationships (Brown & Harris, 1978; Fruzzetti, 1996). People with borderline personality disorder (BPD) and related problems often struggle in relationships that significantly affect their lives and can either promote or interfere with treatment progress. And, of course, people with

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BPD and/or severe problems managing their emotion have a big influence on their own

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relationships and on others.

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Consistent with this view, most modern models of developmental psychopathology are

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transactional, highlighting the bidirectional (or reciprocal) relation between parent behaviors and

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children’s behavior problems. Similarly, partner involvement, or couple interactions, have been shown to be relevant in the development or exacerbation of many forms of psychopathology

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(Fruzzetti, 1996; Fruzzetti & Worrall, 2010), and partner involvement and/or couple interventions can aid in the prevention, treatment, or prevention of relapse in a variety of

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problems (cf. Baucom, Whisman, & Paprocki, 2012). Of course, different models consider

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different transactional factors, but the focus on mutual influence of factors over time is consistent across models (e.g., Leve & Cicchetti, 2016; Serbin, Kingdon, Ruttle, & Stack, 2015). Indeed, a specific bio-social or transactional model is utilized in Dialectical Behavior Therapy (DBT) to understand the development of borderline personality and related disorders of emotion dysregulation. This framework maintains that BPD specifically and emotion dysregulation in general are the product of (and are maintained by) an emotionally vulnerable individual transacting with, and within, an invalidating social environment (Crowell, Beauchaine, & Linehan, 2009; Fruzzetti, Shenk & Hoffman, 2005; Fruzzetti &Worrall, 2010; Grove & Crowell,

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2017). Of course, in the present model the specific parent behaviors (and other caregivers, and later peer and partner behaviors) are invalidating responses, and the child’s (and later adolescent’s and adult’s) behaviors are inaccurate expression, vulnerability to becoming emotionally dysregulated, and pervasive emotion dysregulation. DBT affords multiple pathways to help patients not only improve their relationship skills and employ those skills unilaterally (Linehan, 2015; Rathus & Miller, 2014), but also to

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intervene directly in their close relationships to help improve them via parent, partner, and family

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skill training (Fruzzetti, 2006; Fruzzetti, in press; Hoffman, Fruzzetti, & Swenson, 1999) or DBT

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family therapy (Fruzzetti, 2018; Fruzzetti & Payne, 2015; Fruzzetti, Payne, & Hoffman, in press). Thus, there may be a variety of reasons why a DBT therapist may want to assess directly

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(and likely intervene with) the client’s family and client-family member transactions.

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Assessment Issues and Targets Individual difficulties in DBT are rarely comprehensively understood outside of their

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social context. Evidence suggests that difficulties with severe emotion dysregulation as

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experienced by many DBT clients develop in a complicated transaction in which high emotion vulnerability (e.g., sensitivity, reactivity, and a slow return to emotional equilibrium), growing pervasive emotion dysregulation, and inaccurate expression (of emotions, desires, etc.) elicit increasing invalidating responses from the individual’s social and family environment (see Fruzzetti, 2006; Fruzzetti, et al., 2005; Fruzzetti & Worrall, 2010), and vice-versa. This more desirable, healthy transaction involves two simple steps: (a) accurate expression by one person; and (b) understanding and validating responses by the other (Fruzzetti, 2006). However, emotion regulation or self-management, and awareness (mindfulness of emotions, desires, goals, etc.), are

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necessary precursors to accurate expression, whereas emotion self-management and awareness of the other person’s experience and relationship goals, and awareness of the importance of the relationship itself are precursors to genuine validating responses. Of course, inaccurate expression along with invalidating responses are corrosive to relationships and being invalidated fosters more intense emotional reactions even in people without high emotion vulnerabilities (Shenk & Fruzzetti, 2011).

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Accurate expression is essential in relationships, making the individual’s goals, emotions,

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etc., understandable to the other person. That understanding, and the legitimacy it brings to the

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person’s experiences and behaviors, is the key to eliciting validating responses from others. It is

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simply difficult to understand, and to validate, without knowing what the other person is experiencing, and what that is in response to. Without accurate expression of private events

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(emotions, desires, etc.), partners, parents and others react based on inaccurate expression and

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reactions from similar situations in the past (often full of misunderstanding and high negative emotion). This can lead to “filling in the blanks” inaccurately for the other’s private experiences

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with one’s own assumptions and judgments, leading to more invalidating responses.

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Inaccurate expression includes a variety of problematic communications, both verbal and nonverbal. Verbally, in DBT, it is considered at least partially inaccurate to express either judgments or secondary emotions. For example, saying, “you’re a jerk” is judgmental and is typically expressed in an angry way (anger may not always be a secondary emotion, of course, but when mediated by judgments we would consider it as such). This very likely masks both the more primary emotion in this case (e.g., hurt feelings) and a description of the situation or behavior that resulted in those hurt feelings (e.g., not understanding how important something is to the other person). Accurate expression (e.g., “I’m feeling a bit hurt: I don’t think you are

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listening and understanding how important this is to me”) makes it much easier for the other person to understand, and consequently to validate. Nonverbally, extreme behaviors (such as self-harm, suicide attempts, substance misuse) as well as more ordinary problematic relationship behaviors (verbal attacks or withdrawing from the other person) make it impossible for the other person to know what happened, and difficult to know what the person’s experience was, and thus lead to invalidating responses.

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Conducting a thorough and careful assessment of family interaction, including both the

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skillful and unskillful antecedents to emotion dysregulation that lead into these transactions,

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allows the clinician to gain better understating of both the sources of dysregulation for the client

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and the conflict process in the relationship, with clear and direct implications for targeted intervention. It is important to focus, of course, on accurate vs. inaccurate expression and

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validating vs. invalidating responses.

Basic Structure of Family Assessment

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Because opportunities for family assessment and intervention are often limited, it is

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important to employ efficient procedures and to have clarity about who conducts the assessment.

Who Is the Family Therapist? DBT teams typically include three or more people, often with multiple roles on the team, skill trainer, individual therapist, peer supervisor, skills coach. We will assume that the family therapist also conducts the family assessment, and simply refer to that person as the family therapist, because family assessment and family therapy are so interwoven. This is another role that needs to be incorporated into the team.

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Obviously, in this DBT team context, there are two options: the individual therapist can also be the family therapist, or, a different team member can serve as the family therapist. Although people often have strong opinions about the need to do it one way or the other, there are no data to support one structure versus the other. It is important for all participating members to agree to open discussion in sessions about all relevant issues. Ethically, of course, any adult can terminate permission to disclose or discuss private information, so it is important to get a

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clear agreement keeping communication open. We believe that there are no inherent “dual role”

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problems when the therapist and team opt for the individual therapist also to provide couple or

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family interventions. Of course, the therapist needs to be clear about treatment targets (below),

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and that the therapist is working to improve both the couple/family relationship and the wellbeing of all individuals in those relationships, in typical dialectical (DBT) fashion (see Thorp &

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Fruzzetti, 2003, for a fuller discussion of ethical issues and practices in couple/family therapy).

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In practice there are pros and cons for both options (individual therapist also providing couple/family interventions vs. having a separate couple/family therapist; Fruzzetti, 2018). For

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example, some of the pros of having the individual therapist also be the couple/family therapist

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include: (a) the therapist will have more awareness of the individual client’s problems and prior chains (and solutions), and may be able more effectively to intervene earlier on the chain if problematic transactions emerge in-session; and (b) the therapist will likely be more facile in motivating the individual client in couple/family sessions (e.g., may be able to push harder for change, and/or more efficiently validate). On the other hand, some of the pros of having a different DBT team member take the role of the family therapist include: (a) it may seem more balanced (or simply preferable) to partners or parents that the couple/family therapist be dedicated to this role only, and (b) having an additional person participate directly with the

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family may provide more helpful perspectives for the DBT consultation team to consider. (Note: some teams choose to have the individual therapist also provide family therapy, but have a different therapist provide parent or partner skill coaching.)

Assessment Structure DBT family therapists need to be flexible about how to perform assessments. For

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example, when time allows, there are benefits to conducting a thorough assessment over a couple

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of sessions. After orienting the family to DBT with families, the first session primarily includes

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doing an initial double chain analysis (described below in detail), and spending a few minutes

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alone with the parents or partner, as well as the individual client (to assess potential provocative issues, and/or those related to safety, such as domestic violence). Then, the therapist would give

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the family instructions for the family to engage in certain conversation topics, turn on a video

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recorder, and leave the room for an allotted amount of time (details for these procedures will also be described below). The family might be given one or more self-report questionnaires at the end

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of Session 1 to complete and bring back in Session 2. The second session would include a

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discussion about what the therapist and team observed in the video-recorded interactions and follow-up questions from both the first session and the completed questionnaires. Additional time would be spent orienting to the session and increasing commitment to family work (Fruzzetti & Payne, 2015). However, sometimes a family comes into its first session in the middle of a crisis, and either safety is an immediate treatment target or another family crisis, even if not lifethreatening, is paramount in family members’ minds. In this case, doing more immediate safety planning (Harned et al., 2017) is the primary goal. Even in these cases, the DBT family therapist

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can assess parts of a double chain, and directly observe family interactions for treatment targets. Later sessions can be utilized to complete missing pieces of the assessment when quick intervention is needed in the initial session(s).

Targets for Assessment Similar to individual DBT treatment targets (Linehan, 1993), targets in couple and family

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DBT interventions are organized hierarchically according to behavior severity. Severe and

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dangerous behaviors must be resolved and brought under control before less severe behaviors

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can be addressed. Accordingly, the treatment target hierarchy identifies couple and family targets

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in the same hierarchy as any mode of DBT would, depending on how much they interfere with (1) safety (life-threatening behavior, e.g., patient self-harm, aggression between partners or

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among family members, severe neglect of children), (2) the patient’s active and collaborative

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participation in treatment (treatment-interfering behavior, e.g., parents or partners could discourage or interfere with the client attending individual and group sessions), (3a) basic

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individual and relationship/family stability (severe quality-of-life interfering behavior as it

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relates to couple/family relationships, e.g., imminent separation between the partner and the client, or between an adolescent client’s parents), (3b) invalidating behaviors that affect emotional well-being and/or emotion regulation, (3c) missing validating responses that could be helpful to the patient and couple or family relationships, (3d) ongoing destructive conflicts, and (3e) limited emotional closeness and intimacy in couples (Fruzzetti & Payne, 2015; Fruzzetti, 2006). The treatment target hierarchy also informs assessment, giving the therapist a guide to which interactions to assess first (those highest in the treatment target hierarchy), and about

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which problems to collect relevant information (and what to ignore, or at least delay, attention). While assessing for behaviors within the different levels of the hierarchy, the therapist needs to assess both problem behaviors (lack of skills) and individual and relationship skills that are present. For example, if a family reports a conflict that involves physical violence and difficulty negotiating or enforcing family rules, then physical violence will be assessed (and likely addressed) first, with particular attention to the chain of individual and relationship behaviors

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that lead to the aggression or violence. This often requires the therapist to begin to focus early on

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building emotion and behavioral self-management skills for all family members as a foundation

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for other skills that will be targeted (e.g., problem management) later in treatment. There are a number of behaviors of parents, partners, children, and others that may be

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particularly relevant to client “target behaviors” in Stage 1, including suicide attempts and self-

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harm, substance use, treatment collaboration/treatment interfering behaviors, and so on. Thus,

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the DBT family therapist first identifies the highest target(s) in the hierarchy, and then assesses whether family members have engaged in any behaviors (or their absence) that might be relevant

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to the client’s higher targets. There are four types of problematic family member behaviors that

behaviors:

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need to be identified via chain analysis. The DBT family therapist must assess the following

1. Prompting Events That Initiate Client “Chains” Leading to These Primary Targets It is common for something a parent or partner does or says (or fails to do or say) to elicit negative emotional arousal in the client. This is not to blame the parent or partner, of course, but rather to identify behaviors early on the client’s chain that lead to dysregulated emotion and dysfunctional over behavior. Often, these are clearly critical, judgmental, and/or invalidating

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statements, but sometimes they are more nuanced, and meant in one way (by the family member) and felt in another (by the client). Of course, the goal is not to decide on the veracity of the statements when two people disagree, but to highlight or identify the misstep in communication. Remember, prompting events are simply events that elicit increased negative emotional arousal. Sometimes, these are rather normative (and not obviously or necessarily problematic) behaviors on the part of the family member. However, they do initiate a dysfunctional chain for the client

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and are often are important. For example, for a client who has severe fears of abandonment or

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severe rejection sensitivity, ambiguity in a given situation regarding relationship commitment or

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affection could easily lead to a more problematic emotional response, even if the partner’s or

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parent’s behavior does not reflect any diminished commitment or affection.

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2. Aversive and/or Invalidating Behaviors That Contribute to Further Dysregulation of the

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These partner or parent behaviors (verbal or actions) do not necessarily contribute to a

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person’s initial emotional reactions, but rather can substantially exacerbate already rising

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negative emotional arousal. These may include any of the subtypes of invalidating verbal behaviors (see Table 1), along with other problematic, blaming, critical, or judgmental behaviors. Of course, it is important to remember that invalidating behaviors are not necessarily aversive per se. For example, when a teen is convinced that “nobody likes me,” it is likely invalidating for the parent to say, “oh, that’s not true . . . everyone likes you, sweetie!” Although well-intended and loving, the parent in this situation is invalidating the teen’s present experience, possibly leaving the teen feeling misunderstood and alone.

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The consequences of invalidation can be increased negative arousal, poor conflict management, and distancing. In contrast, validating responses are the core communication responses in close relationships (see Table 1 for different ways to validate in close relationships). Evidence suggests that being validated can soothe negative emotional arousal (Shenk & Fruzzetti, 2011), allowing partners, family members, and loved ones to get through moments of disagreement and conflict without damaging the relationship. Validation slows down reactivity,

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facilities problem solving, and increases closeness and intimacy (Fruzzetti, 2006). There is

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something about feeling understood and accepted that allows us to feel soothed and comforted in

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such a way that makes future disclosure of private experiences more likely. Thus, special

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attention is paid to assessing for invalidating responses.

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3. Positive or Negative Reinforcers for Dysfunctional Behavior

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It is not uncommon for parents or partners to reinforce the client’s suicide attempt or other dysfunctional behavior, albeit typically unwittingly. For example, a family member may

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become more emotionally involved, warmer, more solicitous following a problem behavior,

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likely providing social positive reinforcement. Similarly, a distant, annoyed, or critical family member might, in the face of suicidality or other problem behaviors, become more engaged, express less annoyance (and instead concern), and reduce criticality, thus potentially negatively reinforcing these problem behaviors (Fruzzetti, in press; Fruzzetti & Payne, 2015).

4. Ignoring or Otherwise Failing to Reinforce (or Even Punishing) Nascent or Emerging Skillful Alternatives

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Parents and partners report a lot of burnout vis-à-vis their loved ones with BPD and other disorders related to chronic emotion dysregulation. Thus, it may not be surprising that they sometimes fail to notice or respond to important improvements in their loved ones’ skills and other more functional behaviors. Many problem behaviors in BPD have a social function (Linehan, 1993); thus, failing to receive social reinforcers (or receiving punishing responses) can make learning new, skillful behaviors much more difficult for clients.

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When family member behaviors are linked in the above ways to client problem

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behaviors that are dangerous or extremely problematic, it is clear how important it is both to

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assess fully and, whenever possible, intervene with the family as well as the individual client.

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These are the key targets for assessment of targets relevant to Stage 1 outcomes for the patient. In addition, it is important to note that family members, and family relationships, often

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suffer in these situations. And, even when family member behaviors are not directly relevant to

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dysfunctional client behaviors as noted above, family members may still suffer a great deal (Harned et al., 2017; Hoffman, Fruzzetti & Buteau, 2005, 2007), and their well-being is likely

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linked to the client in a variety of both direct and indirect ways. In these latter situations, the

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same assessment strategies may be employed, with perhaps the less urgent, but still very important, goal of improving family functioning overall.

Double Chain Analysis An essential skill of a DBT therapist assessing couples, parents, and families is the ability to guide the family through a chain analysis. Similar to an individual chain analysis, a “double” chain is a detailed and entirely descriptive exploration of the series of behaviors (both public and private) that led to a problematic or dysfunctional behavior. In doing so, it is important for the

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therapist to guide each individual in clearly defining behaviors in each link on the chain. Behavioral specificity is important during double chain analyses as it allows clients and family members to focus on descriptive reality (instead of judgments), can help prevent escalating emotional arousal during chain analyses, and facilitate understanding of the behaviors being described. Each individual (partner, parent or family member) describes his or her own “chain,” while the therapist draws a picture of the transaction as two chains emerge, synchronized over

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time (Figure 1). The therapist’s job is to coach each individual to express him- or herself

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accurately and nonjudgmentally and seek to understand each other’s experience. Managing and

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targeting the behavior of multiple people in session can be challenging as one individual’s behavior in session may elicit difficult emotion, judgments and dysregulation on the other (this

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also has the benefit of bringing the “problem behavior” right into the therapy session, for direct

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intervention). Nevertheless, the therapist sometimes works much like a traffic cop, guiding each

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individual to engage in skillful behavior during the session, blocking invalidating responses (or facilitating validation) and building commitment both to treatment and to skillful solutions.

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The therapist models many of the skills and validates the valid thoughts, wants, and

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emotional responses of each family member along the way, demonstrating skillful responses and alternatives for the clients and cheerleading their new steps (Fruzzetti & Ruork, 2018). Much like the process of individual chain analysis (e.g., Rizvi & Ritschel, 2014), a double chain analysis is an opportunity for both assessment and intervention. The goal is to understand the antecedents and consequences of a problematic behavior in order to facilitate the generation of possible solutions. Typically, in individual chain analysis the therapist and client will discuss the client’s behavioral chain (vulnerabilities, thoughts/judgments, emotions, sensations, actions) and then identify and practice possible solutions to “break the chain.” All

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events are understood primarily from the perspective of the client. In a double chain analysis, each individual’s chain is described, including points in which their chains intersect and affect each other. These “public” links are shaded in Figure 1, and only one occurs at any given moment, highlighting actions or verbal behaviors that are relevant to both people. In contrast, the “open” links are drawn for each person simultaneously. A double chain thus can illuminate a great deal about the transaction between one individual’s overt behavior and the other’s

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dysregulated emotion (and vice-versa), allowing for the selection of specific targets to treat,

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relationship skills, as well as mutual understanding.

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ultimately replacing problematic reactions and other behaviors with new emotional or

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To begin a double chain analysis, the therapist (with input from the family) selects a specific instance (specific day, time, and place) of a problem or conflict. Each family member

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then goes though the links on the chain, including vulnerabilities, thoughts, urges, emotions, and

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actions (verbal or other). As shown in Figure 1, the shaded links represent the public events and the nonshaded links represent private experiences (thoughts, emotions, desires, etc.), that can

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only be understood once disclosed in an accurate way. Each individual has the opportunity to

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disclose his or her experiences and validate the valid parts of the other’s experiences. With this greater knowledge of the chain of events, each person can discuss and practice skillful alternatives to “break the chain” and end the interaction in a completely different manner. In the session, one or more people may be dysregulated, and conducting a double chain analysis (or any meaningful exchange) may be difficult. DBT couple and family therapists may need to utilize various session-management strategies in order to run the session effectively. These include blocking dysfunction early, inviting accurate expression, providing at least minimal validation to soothe negative emotional arousal, making sure not to show up parents or

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partners (instead, try to make them look good and build competence), real-time skill coaching in the session, and even employ a “revolving door” in which more regulated and collaborative family members spend short periods of time in the waiting area while the therapist tries to understand, block, and teach relevant skills to the more dysregulated family member to allow for meaningful discourse in the session together (see Fruzzetti & Payne, 2015, for more details about these strategies).

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Let’s consider an example of a double chain analyses in the case of Jamie, a 15-year-old

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girl who has just begun DBT following a suicide attempt, and her mother. In the session, prior to

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explicating their chains and how they affected each other, Jamie was blaming and judgmental of

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her mother, and her mother was blaming and judgmental of Jamie. What follows is a narrative summary of the key elements of their chains that were discovered during a careful double chain

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analysis:

Jamie struggles with relationships, identity issues, dysregulated emotions, and urges to

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self-harm. She and her parents are coming in for their first family session. Jamie has reported

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that her suicide attempt followed an argument with her mother in which she says that her mother was picking on her, was critical of her, and that Jamie felt like her mother just hated her. Her mother’s report was that Jamie was being obstinate and was not getting her homework done and was in danger of flunking several of her courses and not advancing to her sophomore year. Immediately, Jamie and her mother started arguing, while Jamie’s father looked overwhelmed and stayed silent, simply saying that he was at work and didn’t know what had happened. Jamie had been struggling with homework almost every day after coming home from school, and her grades had dropped a lot from 8th grade to 9th grade. She typically tried to do homework in her

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room, alone, and her parents were not aware how much time she spent trying to get things done. Her mother, it turned out, assumed that she was in her room primarily spending time on social media. In fact, Jamie had few friends and was very lonely, full of self-doubt. On the day of the argument that led to her overdose (of over-the-counter pain medicine), Jamie had experienced several disappointing social interactions in which she tried to affiliate with other teens but was not successful, felt rejected, lonely, and was judgmental about herself (e.g., “I’m such an idiot”)

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and found it particularly difficult to concentrate. She did not see her mother when she got home

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from school and went straight to her room. After trying to do her homework for almost an hour

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(but mostly judging herself and ruminating about her failed social relationships), she threw her

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books against the wall, yelled that she hated school and slammed her door shut. Jamie’s mother, thinking that she was on social media and feeling worried about her plummeting grades, went to

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Jamie’s room and told her that she needed to “cut the drama and just get her homework done.”

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When Jamie told her that she just wanted to listen to some music for a few minutes (Jamie’s intention was to try to calm herself down), Jamie’s mother told her that she could not do

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anything else until her homework was completed. Verbal conflict escalated, and both of them

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said nasty things to each other. Jamie’s mother called Jamie “lazy and entitled” and other critical and invalidating things, and then Jamie locked herself in her bedroom, and her mother felt guilty and overwhelmed and went to the kitchen and turned on the television. Jamie reported feeling so overwhelmed, lonely, misunderstood, and so on that she could not stand it, and soon went out to the bathroom and found a bottle of nonprescription pain medicine and swallowed the whole bottle. She went back to her room and got into bed, pulling the blanked up over her head, and fell asleep. She woke up sometime later with pain in her abdomen, and then told her mother

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what she had done and was taken by ambulance to the hospital. Jamie’s mother rode with her in the ambulance and was soothing and apologetic about the things she had said. The left sides of Tables 1 and 2 list problematic targets on the chain to look out for in general. It is clear from the chain that Jamie’s inability to express herself accurately (e.g., that she had tried hard to do her homework, that she felt lonely and hopeless about her lack of good social relationships) made it very difficult for her mother to understand what was going on for

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her and to respond differently. Jamie simply did not have the skills to focus her attention on her

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homework tasks effectively.

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Similarly, Jamie’s mother had a lot of interpretations of Jamie’s behavior that were mostly inaccurate (e.g., that Jamie was using social media rather than doing homework, that her

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failure to complete homework was due to being lazy), ultimately invalidating of Jamie’s

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experience. However, there were some public behavior that Jamie’s mother might have used as

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“clues” to Jamie’s distress, such as Jamie throwing her books against the wall and slamming the door. When she told her simply to stop this behavior (a reasonable request, especially in a

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different context), she completely missed an essential piece of Jamie’s expression: throwing her

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books and slamming the door were somewhat (albeit partial) accurate expressions of her distress that made sense, given what had been going on for her at school. Throwing the books and slamming the door also suggested that Jamie was having difficulty regulating her emotions at the moment. Thus, while Jamie’s mother’s requests may have been reasonable in many situations, they were invalidating of Jamie’s actual private experiences (dysregulation, extreme loneliness, fear) in this situation. In this transaction, Jamie’s difficulties and her mother’s responses fueled each other: Jamie’s inaccurate expression made it easy for her mother not to understand Jamie’s

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emotions, and her mother’s invalidating responses contributed to further negative emotional escalation for Jamie, and so on. Without her mother’s invalidating responses, and likely with a more validating response, Jamie might have been able to regulate her emotions more quickly, engage in meaningful problem solving, and not have overdosed. Similarly, if Jamie had expressed herself more accurately, her mother would have understood much more and more easily would have been able to respond in a validating way.

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It is important to note that the essence of the double chain—understanding the actual and

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valid pathways of each person’s behaviors, and how each person influence the other—would not

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have been possible with an ordinary discussion about “what happened” that day. The double

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chain provides precision, opportunities for mutual understanding and more validating responses,

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deficits and other treatment targets.

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helps both people feel understood (and neither blamed or judged), and clearly identifies skill

Evaluating Behavior Samples: Direct Behavioral Observation

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Although extremely useful in its detail, and integration with teaching skills and other

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family interventions, double chains can take a lot of time, and there are times when problem behaviors simply unfold right in front of the therapist. Thus, the other essential tool for family assessment in DBT is direct observation of family interactions. Observing live, or video recorded, conversations of couple and family interactions can provide a clinician with a more objective measure of individual and relationship skills for each person if specific targets are clearly specified (e.g., Tables 1 and 2), and identify clear examples of problematic (or skillful) behaviors, and can do so quickly and efficiently.

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It is essential to remember that there are many socio-cultural barriers that lead to significant disparities in the delivery of all health care, including mental health and family health interventions (Betancourt, Green Carrillo & Ananeh-Firempong, 2003), and that the initial assessment is often the first point of contact for couples and families, as well as individuals, seeking help. It is also important to recognize that families live in their own social and cultural context, nested within other social and cultural structures, which may or may not be very similar

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to that of the therapist. That is why the therapist must bring cultural competence (cf. Sue, 2001),

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as well as a healthy dose of curiosity, to the assessment process. Key functions of behavior such

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as inaccurate expression or invalidating responses between partners or between parents and

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children, or other interaction patterns in couples or families, are likely universal, across cultures (e.g., Christensen et al., 2006). However, the form of these behaviors may vary greatly from

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person to person, couple to couple, and family to family, depending on their culture. The

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therapist must be expert in asking questions about the function and meaning of key behaviors and sensitive about attending to the function, and not form, or what partners, parents, and

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children do. For example, what constitutes “loud yelling” that communicates judgment in the

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therapist’s culture might be ordinary attentive communication that expresses emotion accurately without judgment in some families. Similarly, what feels like passive and indirect communication that is likely inaccurate to the therapist might be well understood by the client and his or her parents or partner. Or, it might vary greatly from person to person within the family. It is thus essential to develop good rapport with the family to help them focus on the functions, meaning, and impact of their behavior first. The focus on the form of the behavior is relevant only to the extent that it helps to change its function and generate more skillful behavior.

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In the following example, Mary, who is in standard outpatient DBT, struggles with severe emotion and behavioral dysregulation and consistently reports conflict with her partner, Jack. On her DBT diary cards, and according to Mary on most subsequent chains, conflict with Jack has been either the event leading to dysfunctional behavior, or creates a significant vulnerability, since she began DBT. Of particular interest is how Mary expresses her thoughts and emotions to Jack. In individual therapy, they spent considerable time targeting Mary reducing her threats of

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suicide and self-harm in particular, which Mary had often made in the middle of conflict.

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On several occasions Mary tried to bring up with Jack her feelings of distance from him.

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Mary had practiced this in session in role-plays with her therapist, using a lot of skills, not being

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demanding or blaming. Despite her efforts, she felt that Jack did not listen to her, and generally was very condescending toward her and her wanting more closeness.

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By including Jack in the session for further assessment, the therapist hoped to gain a

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better understanding of the problematic “links” for Mary, and why her attempts to express herself accurately were not effective. Was Mary really being as effective as she claimed? Was

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she leaving anything out? Was Jack as condescending as Mary described? Without direct

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observation, it would be impossible to know what to work on. Another example of this kind of interaction occurred, which Mary reported on her diary card: she reportedly expressed her emotions accurately, but subsequently felt that Jack shut down and was very invalidating and condescending (telling her to calm down when she didn’t think she was expressing much intensity). She doubted herself, however, and thought that maybe she had not realized that she had been “acting way out of control” and was not very skillful after all. This led her to become more hopeless and she became more suicidal.

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The therapist arranged a joint session with Mary and Jack and noticed that Jack seemed to become quite fearful of the possibility that Mary would attempt suicide or self-harm whenever Mary mentioned that she was experiencing negative emotions. Jack was fearful even in situations when Mary was clearly expressing primary emotions that she readily could manage without escalating. Instead of allowing Mary to express herself, or really trying to understand and validate (and possibly problem solve together), in the session he attempted to calm her down

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(even though she was not upset) by telling her that it was not good for her to get so upset and it

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was best not to discuss this further because she might become too upset. Of course, this

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invalidated Mary’s experience (her feeling distant, wanting to discuss it, and basic competence to

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be upset without becoming dysregulated).

Without necessarily needing to do a comprehensive double chain analysis, the therapist

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asked what Jack was noticing right at that moment (thinking, feeling, wanting) when he became

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apparently fearful and tried to calm a not-upset Mary. Jack finally acknowledged, with Mary out of the room, that he was deeply afraid she might kill herself, and thus became afraid any time

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Mary expressed negative emotions or unhappiness. On the one hand, this was completely invalid,

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given that she was not dysregulated and not even thinking about suicide, was not being coercive, and she had a clear and skillful plan to try to be heard and understood. Jack was misunderstanding Mary’s attempts to use her skills in expressing her experience more accurately. On the other hand, drawing from his history with Mary, he was interpreting her attempts to engage as moments of dysregulation, or at least imminent dysregulation. Before she began treatment, it was common for Mary to express intense negative emotions when feeling dysregulated, often leading to expressions of self-hatred and threats of suicide. Her family, including Jack, believed her expression of emotion was disproportionate with the intensity of the

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event and often unpredictable. They quickly learned that these expressions were a sign of subsequent self-harm. When we understand this pattern, it is easy to see how Jack may unintentionally invalidate Mary when using new skills to express herself. Instead of listening and trying to understand, Jack became overwhelmed with fear. His invalidating responses not only made it harder for Mary to continue using her skills, but also inadvertently punished her attempts to be skillful.

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By knowing what to look for, and jumping in on Jack’s initial invalidating responses to

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Mary, the therapist was able to identify the key problem in their interactions that resulted in both

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of them becoming miserable, and that also created a lot of distance in their relationship. Conflict in this manner previously had inevitably escalated, leaving both partners feeling invalidated and

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misunderstood in their efforts. However, by immediately catching Jack’s invalidating response,

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efforts to help him be more mindful of Mary’s present skills and present emotion (quite within

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normal limits), Jack was able to respond to Mary very differently. Similarly, by understanding the source of his invalidating behavior (his fear of her becoming suicidal), Mary could be tasked

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with more accurate expression about her self-management and her safety.

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Tables 1 and 2 (left columns) show which behaviors the DBT family therapist needs to look for, and the right columns identify skillful alternatives. By focusing on the behaviors as they unfold, and understanding the transaction, the therapist can quickly and precisely target the problematic common behaviors across multiple transactions, or patterns of interaction. Interventions can be targeted on both “sides” of the transaction, that is, helping individuals struggling with emotion dysregulation difficulties and their family members learn skills to regulate emotions and communicate more effectively while also increasing validating responses. If even one person can respond more effectively, it creates the opportunity for the transaction to

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be different. As one individual learns to expresses his or her thoughts, emotions, wants, and desires more accurately, it makes it easier for the other to validate, thus creating a new two-step pattern of transactions that allows for closeness and understanding. There may be times when the problems in the transaction are more nuanced and the therapist might want to observe things more slowly or seek guidance from DBT consultation team members. In these cases, it is useful to record the family’s conversations. With modern

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technology, this is simple, efficient, and inexpensive to do. The therapist simply gives the family

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(couple, or parent(s) and teen, etc.) instructions to talk for about 10 minutes about a key and

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provocative problem about which is a common conflict topic. If family members disagree about

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what the problems are, each might pick a problem for discussion, with 7 to 10 minutes dedicated to each topic. In addition, the therapist might simply ask the family to discuss how their family

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relationships are going, and any changes that they might want to see from each other (Fruzzetti

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& Jacobson, 1992; Snyder, Heyman, & Haynes, 2008). The therapist simply turns on the camera and microphone on the way out of the room, and off when he or she returns.

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Subsequently, the therapist may review the conversation, looking for important treatment

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targets, using Tables 1 and 2. The whole DBT consultation might watch part or all of a conversation to help the therapist, and the therapist might even review the video with the family in the subsequent session. Note: It is important never to leave a video or audio recording of these interactions anyplace that could be accessed by anyone other than the therapist or DBT consultation team, to encrypt the files, never leave them accessible to the internet, and to destroy the files after use (see Thorp & Fruzzetti, 2003, for other ethical considerations). Although assessment and intervention are traditionally thought of as separate components, in DBT with couples and with families (as well as with individuals), these clear

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distinctions are not always accurate. Although we must first thoroughly assess the problem before implementing an intervention strategy based on the findings during the assessment process, intervention also can be immediate. After an intervention is delivered, additional assessment is required to determine whether change has occurred. In reality, assessment and intervention are occurring continuously throughout treatment in a dialectical way. Assessment is an opportunity for therapist, clients, and family members to understand, accept, and validate each

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individual’s experiences. It is also through the process of assessment that the therapist can

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identify treatment targets and understand the “chain” of behaviors that resulted in dysfunctional

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behavior. During the process of a chain analysis and solution analysis in the session, for

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example, problematic behaviors inevitably occur that can be observed (and treated) directly. Emotions go up, often to the point of dysregulation, and problematic patterns arise. These

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assessment moments become intervention opportunities: the therapist can block, elicit or teach

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skills, model validation, or embark on any number of other intervention strategies (Fruzzetti,

Conclusions

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2018; Fruzzetti & Payne, 2015).

Assessment of couples, parents, and families is an essential part of DBT interventions with couples and families but is important even when family interventions are not planned. Assessment targets reflect treatment targets, and allow the DBT individual, couple, or family therapist an efficient way to structure subsequent interventions. The two main clinical assessment tools, the double chain, and direct behavioral observation, each have advantages and disadvantages, and can be combined for comprehensive yet efficient and comprehensive family assessment.

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References Baucom, D. H., Whisman, M. A., & Paprocki, C. (2012). Couple-based interventions for psychopathology. Journal of Family Therapy, 34, 250-270. doi.org/10.1111/j.14676427.2012.00600.x Betancourt, J. R., Green, A., Carrilllo, J. E., & Ananeh-Firempong II, O. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in

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health and health care. Public Health Reports, 118, 293-302.

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disorder in women. London: Tavistock.

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Brown, G.W., & Harris, T.O. (Eds.). (1978). Social origins of depression: A study of psychiatric

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Christensen, A., Eldridge, K., Catta-Preta, A. B., Lim, V. R., & Santagata, R. (2006). Crosscultural consistency of the demand/withdraw interaction pattern in couples. Journal of

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Marriage and Family, 68, 1029–1044.

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Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehan’s theory. Psychological

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Bulletin, 135, 495-510.

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Fruzzetti, A. E. (1996). Causes and consequences: Individual distress in the context of couple interactions. Journal of Consulting and Clinical Psychology, 64, 1192-1201. Fruzzetti, A. E. (2006). The high conflict couple: A dialectical behavior therapy guide to finding peace, intimacy, and validation. Oakland, CA: New Harbinger Publications. Fruzzetti, A. E. (in press). Families and borderline personality disorder: A dialectical behavior therapy guide to finding peace in your family. Oakland, CA: New Harbinger.

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Fruzzetti, A. E. (2018). Dialectical Behavior Therapy with parents, couples and families to augment Stage 1 outcomes. In M. Swales (Ed.), Oxford Handbook of Dialectical Behaviour Therapy. London: Oxford University Press. Fruzzetti, A. E., & Jacobson, N. S. (1992). Couple assessment. In J. C. Rosen & P. McReynolds (Eds.), Advances in psychological assessment, Vol. 8 (pp. 201-224). New York: Plenum. Fruzzetti, A. E. & Payne, L. G. (2015). Couple therapy and the treatment of borderline

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personality and related disorders. In A. Gurman, D. Snyder, & J. Lebow (Eds.), Clinical

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handbook of couple therapy (5th ed., pp. 606-634). New York: Guilford Press.

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Fruzzetti, A. E., Payne, L., & Hoffman, P.D. (in press). Dialectical Behavior Therapy with families. In L. A. Dimeff, K. Koerner, & S. Rizvi (Eds.), Dialectical behavior therapy in

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clinical practice: Applications across disorders and settings (2nd ed.). New York:

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Guilford Press.

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Fruzzetti, A. E., & Ruork, A. (2018). Validation principles and practices. In M. Swales (Ed.), Oxford Handbook of Dialectical Behaviour Therapy. London: Oxford University Press.

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DOI: 10.1093/oxfordhb/9780198758723.013.50

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Fruzzetti, A. E., Shenk, C., & Hoffman, P. D. (2005). Family interaction and the development of borderline personality disorder: A transactional model. Development and Psychopathology, 17, 1007-1030. Fruzzetti, A. E., & Worrall, J. M. (2010). Accurate expression and validation: A transactional model for understanding individual and relationship distress. In K. Sullivan & J. Davila (Eds.), Support processes in intimate relationships (pp. 121-150). New York: Oxford University Press.

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Grove, J. L., & Crowell, S. E. (2017). Invalidating environments and the development of borderline personality disorder. In M. Swales (Ed.), The Oxford Handbook of Dialectical Behaviour Therapy. doi: 10.1093/oxfordhb/9780198758723.013.47 Harned, M. S., Lungu, A., Wilks, C. R., & Linehan, M. M. (2017). Evaluating a multimedia tool for suicide risk assessment and management: The Linehan suicide safety net. Journal of Clinical Psychology, 73, 308-318.

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Hoffman, P. D., Fruzzetti, A. E., & Buteau, E. (2007). Understanding and engaging families: An

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education, skills and support program for relatives impacted by Borderline Personality

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Disorder. Journal of Mental Health, 16, 69-82.

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Hoffman, P. D., Fruzzetti, A. E., Buteau, E., Penney, D., Neiditch, E., Penney, D., Bruce, M., & Hellman, F., & Struening, E. (2005). Family Connections: Effectiveness of a program

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for relatives of persons with borderline personality disorder. Family Process, 44, 217-

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Family skills training. Family Process, 38, 399-414.

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Leve, L.D. & Cicchetti, D.C. (2016). Longitudinal transactional models of development of psychopathology. Development and Psychopathology, 28, 621-622. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M.M. (2015) DBT Skills Manual (2nd Ed). New York: Guilford Press. Rathus, J.H., & Miller, A.L. (2014). DBT Skills Manual for Adolescents. New York: Guilford Press.

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Rizvi, S. L., & Ritschel, L A. (2014). Mastering the art of chain analysis in dialectical behavior therapy. Cognitive and Behavioral Practice, 21, 335-349. Serbin, L., Kingdon, D., Ruttle, P., & Stack, D. (2015). The impact of children's internalizing and externalizing problems on parenting: Transactional processes and reciprocal change over time. Development and Psychopathology, 27(4pt1), 969-986. Shenk, C. & Fruzzetti, A. E. (2011). The Impact of Validating and Invalidating Responses on

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Snyder, D. K., Heyman, R. E., & Haynes, S. N. (2008). Couple distress. In J. Hunsley & E. Mash

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Psychologist, 29, 790-821.

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Sue, D. W. (2001). Muiltidimensional facets of cultural competence. The Counseling

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Thorp, S. R., & Fruzzetti, A. E. (2003). Ethical principles and practice in couple and family therapy. In W. O'Donohue & K. Ferguson (Eds.), Handbook of professional ethics for

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psychologists: Issues, questions, and controversies (pp. 391-405). Thousand Oaks, CA:

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Sage Publications.

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Table 1 Assessment Targets: Types of Invalidating and Validating Behaviors in Families Validating Responses 1. Paying attention, listening, including ordinary nonverbals; patience, waiting to take turns; not talking over the other

2. Not participating actively, missing ordinary conversational validation opportunities; paying attention but being functionally unresponsive; not acknowledging the obvious, withholding

2. Reflecting or acknowledging the other’s expression or disclosures, including what she or he is thinking/feeling/wanting; or functionally responding to her/him by answering or problem-solving

3. Telling the other person what she or he does feel, think, want, etc., or insisting, even when the other provides contradictory statements; or telling what she or he should or shouldn’t feel

3. Articulating/offering ideas about what the other might want, feel, think, etc., in an empathic (not insistent) way; helping the other to clarify; asking questions to help clarify

4. Agreeing with other person’s selfinvalidation when his or her behavior makes sense and problems are not central; increasing the negative valence of problem behavior

4. Recontextualizing the other’s behavior (including feelings, desires, thoughts); putting less negative spin on it; acceptance; reducing the negative valence of problem behavior

5. Pathologizing, criticizing other’s behavior when the behavior is actually reasonable or normative in the present circumstances

5. Normalizing other’s normative or reasonable behavior; e.g., “anyone (or I) would feel the same way in this situation”

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1. Not paying attention, being distractible, changing the subject, being anxious to leave or to end the conversation; talking over the other

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Invalidating Responses

6. Patronizing, condescending, and/or contemptuous behavior toward the other; treating the other as not equal (less than) or incompetent; character assaults and/or over generalizing negatives

6. Empathy, respect, and acceptance of the person in general; acting from balance about the relationship; not treating the other as fragile or incompetent, but rather as equal and competent; staying descriptive and nonjudgmental

7. Leaving the other person hanging out to dry: not responding to (validating) her or his vulnerable self-disclosures, thereby assuming a more powerful position

7. Reciprocal (or matched) vulnerability: equal self-disclosure in the context of the other’s vulnerability, maintaining equal (or appropriate in parent/child situation) power distribution

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Table 2 Assessment Targets: Skill Deficits and Skillful Alternatives Skill deficits

Skillful alternatives Emotion awareness, emotion regulation, relationship mindfulness, distress tolerance

Judgmental reactions (private) toward oneself or the other person

Mindfulness and relationship mindfulness: description; awareness of the importance of the relationship and long-term goals

Inaccurate appraisals, or extreme negative future appraisals

Mindfulness: description, present moment

Inaccurate expression (secondary emotions, judgments rather than description, etc.)

Accurate expression of primary emotions, thoughts, desires, long-term goals, importance of the relationship

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Emotion self-management, including high emotion reactivity

Invalidating responses (see Table 1)

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Expressing hurtful criticism, relationship burnout; failing to understand the other person

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Avoiding or leaving (escaping) a conversation

Relationship mindfulness

Validating responses (see Table 1) Mindfulness (present moment, goals, and effectiveness) and relationship mindfulness (relationship goals)

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Highlights:

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Utilizing a transactional model to understand family interaction has several key benefits. The core relationship transaction is how emotion dysregulation and inaccurate expression lead to invalidation responses. Two core assessment procedures are highlighted, with clinical examples. Both assessment procedures allow treatment targets to be identified efficiently.

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Figure 1