University of Northern Colorado Scholarship & Creative Works @ Digital UNC Dissertations Student Research 12-1-2014 Understanding dialectical behavior therapy through the voice of adolescent clients in a community mental health center Jessica Riedel Chenoweth Follow this and additional works at:http://digscholarship.unco.edu/dissertations Recommended Citation Chenoweth, Jessica Riedel, "Understanding dialectical behavior therapy through the voice of adolescent clients in a community mental health center" (2014).Dissertations.Paper 236. This Text is brought to you for free and open access by the Student Research at Scholarship & Creative Works @ Digital UNC. It has been accepted for inclusion in Dissertations by an authorized administrator of Scholarship & Creative Works @ Digital UNC. For more information, please contact [email protected]. UNIVERSITY OF NORTHERN COLORADO Greeley, Colorado The Graduate School UNDERSTANDING DIALECTICAL BEHAVIOR THERAPY THROUGH THE VOICE OF ADOLESCENT CLIENTS IN A COMMUNITY MENTAL HEALTH CENTER A Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Jessica Riedel Chenoweth College of Education and Behavioral Sciences Department of Counseling Psychology December 2014 This Dissertation by: Jessica Riedel Chenoweth 
 Entitled: Understanding Dialectical Behavior Therapy Through the Voice of Adolescent Clients in a Community Mental Health Center has been approved as meeting the requirement for the Degree of Doctor of Philosophy in College of Education and Behavioral Sciences in Department of Counseling Psychology Accepted by the Doctoral Committee ____________________________________________________________ Mary Sean O’Halloran, Ph.D.,Research Advisor ____________________________________________________________ Stephen L. Wright, Ph.D., Committee Member ____________________________________________________________ Joseph N. Ososkie, Ph.D., Committee Member ____________________________________________________________ John Mark Froiland, Ph.D., Faculty Representative Date of Dissertation Defense:____________________________________ Accepted by the Graduate School _________________________________________________________ Linda L. Black, Ed.D. Dean of the Graduate School & International Admissions ABSTRACT Chenoweth, Jessica Riedel. Understanding Dialectical Behavior Therapy Through the Voice of Adolescent Clients in a Community Mental Health Center. Published Doctor of Philosophy dissertation, University of Northern Colorado, 2014. Dialectical behavior therapy (DBT) has recently been shown to be an effective therapy for treating adolescents with suicidal and self-harming behaviors. Despite the growing interest of DBT, there is a lack of research on the subjective experiences of DBT from the perspectives of adolescent clients. Therefore, the purpose of this qualitative study was to explore how adolescents experienced DBT in a community mental health setting. Using constructivist, case study methodology, semi-structured interviews were conducted with nine adolescent participants. Findings emerged from the shared experiences of the participants including themes related to treatment modality, use of skills, and the impact of DBT on their lives. Participants reported beneficial results such as decreased suicidality and self-harming behaviors, improved ability to tolerate distress, increased mindfulness and emotion regulation, and healthier relationships with others. Negative experiences included difficulty understanding DBT terminology, too broad of an age range in group therapy, and inconsistent family involvement. Clinical implications and future research directions for the use of DBT with adolescents were discussed. Keywords: adolescent, dialectical behavior therapy, community mental health, self-harming behaviors, suicidality iii ACKNOWLEDGEMENTS I would like to thank all of the adolescents who contributed to this study. It was an honor to hear your experiences, both painful and joyful, and I appreciate the courage it took for you to share them. It is my hope that this study will benefit other adolescents who may be facing similar problems. My research advisor, Dr. Mary Sean O’Halloran, provided me with the flexible but firm structure I needed in order to complete this project. I cannot express my gratitude enough for her support and encouragement throughout this process. I would also like to thank the other members of my committee, Dr. Stephen Wright, Dr. Joe Ososkie and Dr. John Froiland for their commitment to this project. To my family and friends- thank you for believing in my ability to succeed and for giving me what I needed to do so, whether it was tough love or a much needed laugh. I am especially thankful for my parents, Cathy and David Riedel, whose unwavering love and unconditional support helped me overcome this challenge, as well as many other challenges. Thank you for not only setting the bar high, but for helping me reach it. Finally, I would like to express my deepest love and appreciation for my husband and partner in life, Cody Chenoweth. You make me a better person in all things. This dissertation is dedicated to you with unending love and eternal gratitude. iv TABLE OF CONTENTS CHAPTER I. INTRODUCTION ................................................................................... 1 Statement of the Problem ................................................................................... 3 Purpose of the Study .......................................................................................... 5 Significance of the Study ................................................................................... 6 Guiding Questions ............................................................................................. 7 Rationale ............................................................................................................ 7 Conclusion ....................................................................................................... 11 Delimitations .................................................................................................... 12 Definitions........................................................................................................ 12 Overview of Remaining Chapters .................................................................... 14 CHAPTER II. LITERATURE REVIEW .................................................................... 16 Adolescent Development ................................................................................. 16 Borderline Personality Disorder ...................................................................... 24 Biosocial Theory of Borderline Personality Disorder ..................................... 27 Dialectical Behavior Therapy .......................................................................... 36 Adolescent Dialectical Behavior Therapy Treatment and Adaptations ........... 61 Outcome Research of Dialectical Behavior Therapy ....................................... 70 Adolescent Dialectical Behavior Therapy Outcome Research ........................ 71 Dialectical Behavior Therapy for Women Diagnosed with Borderline Personality Disorder............................................................................. 75 Additional Disorders Treated by Dialectical Behavior Therapy ..................... 85 Conclusion ....................................................................................................... 89 Literature Review Limitations ......................................................................... 90 CHAPTER III. METHODOLOGY ............................................................................. 91 Constructivist Theoretical Framework ............................................................ 92 Constructivist Theory and Dialectical Behavior Therapy ............................... 94 Methodological Framework ............................................................................. 95 Personal Stance ................................................................................................ 98 Description of the Setting and Program ......................................................... 104 Methods.......................................................................................................... 107 Summary ........................................................................................................ 125 v CHAPTER IV. FINDINGS: ADOLESCENTS’ INDIVIDUAL EXPERIENCES ... 127 Jeremy ............................................................................................................ 128 Casey .............................................................................................................. 134 Tara ................................................................................................................ 143 Selena ............................................................................................................. 150 Davey ............................................................................................................. 157 Anna ............................................................................................................... 165 Adam .............................................................................................................. 172 Jade ................................................................................................................ 180 Jose ................................................................................................................. 188 Summary ........................................................................................................ 194 CHAPTER V. FINDINGS: SHARED EXPERIENCES ........................................... 196 Themes Related to Treatment Modality ........................................................ 198 Themes Related to Skill Modules .................................................................. 207 Suggestion for Improvement/Negative Experience Themes ......................... 214 Summary ........................................................................................................ 216 CHAPTER VI. DISCUSSION................................................................................... 217 Summary of the Study ................................................................................... 217 Overview of the Dialectical Behavior Therapy Program .............................. 218 Discussion of the Findings ............................................................................. 219 Themes Related to Negative Experiences or Suggestions for Improvement . 256 Clinical Implications ...................................................................................... 260 Limitations and Future Directions ................................................................. 264 Conclusion ..................................................................................................... 268 REFERENCES .......................................................................................................... 270 APPENDIX A. RECRUITMENT FLYER ................................................................ 293 APPENDIX B. CONSENT FORM FOR HUMAN PARTICIPANTS IN RESEARCH ................................................................................................... 295 APPENDIX C. ASSENT FORM FOR HUMAN PARTICIPANTS IN RESEARCH ................................................................................................... 299 APPENDIX D. INSTITUTIONAL REVIEW BOARD APPROVAL ...................... 302 APPENDIX E. INTERVIEW TOPICS AND POSSIBLE QUESTIONS ................. 305 APPENDIX F. MANUSCRIPT ................................................................................. 307 vi LIST OF TABLES 1. Participant Demographics .............................................................................. 110 2. Themes Related to Components of Dialectical Behavioral Therapy and Negative Experiences .............................................................................. 197 vii CHAPTER I INTRODUCTION Some Call Some call it crazy Some say it’s sick But I think it is freedom The pain is fierce but quick Some say that it’s a sin Just a little too risqué But it helps release the pain That I go through every day The blade is sharp and cold As it runs across my skin Leaving me to ponder And decide how deep I cut in The icy chill running down my spine Makes me feel at ease I no longer feel like a coward Fucking up on everything with every breath I breathe But some days I want to stop Feeling like everything's wrong Trying to let go of the blade Sometimes I can but not for long It’s like I'm addicted to the pain The feeling taking refuge in my veins Leaving me feeling confused and alone Wiping at the streaked tears that seem to be stained Burned into my skin forever Becoming a part that I cannot escape Sometimes I just want to hurt all over To scream at the top of my lungs until they break 2 I want to escape from my sadness It’s taking over me Why can’t I just rest Why won’t it let me be I just want to be free. (Johnson, 2007) Recently, there has been an increase in the number of adolescents seeking psychological treatment for recurrent suicidal ideation, suicide attempts, and self-harming behaviors (Choate, 2012). In the United States, suicide is the third leading cause of death among persons aged 15-24 years (Centers for Disease Control and Prevention, 2011). In a 2011 nationally-representative sample of youth in grades 9-12, it was found that regarding the 12 months preceding the survey, 15.8% of students reported they had seriously considered attempting suicide; 12.8% of students reported they made a plan about how they would attempt suicide; 7.8% of students reported they had attempted suicide one or more times; and 2.4% of students reported they had made a suicide attempt that resulted in an injury, poisoning, or an overdose that required medical attention (Centers for Disease Control and Prevention, 2011). The most common forms of self-injury include cutting, burning, branding, piercing, and self-hitting (Aguirre, 2007; Grunbaum et al., 2004). While self-injurious behavior differs from suicidal behavior with regard to intent to die, there are dangerous effects from self-injury (Choate, 2012): infections and medical risks, permanent scarring, and the risk of unintentional death (Aguirre, 2007). Research shows that without treatment, adolescents will likely continue to engage in self-injurious behaviors into adulthood (Wagner & Linehan, 2006). Self-injurious behaviors and suicide attempts are the most common symptoms among adolescents diagnosed with borderline personality disorder (BPD) or with BPD