Understanding dialectical behavior therapy through the voice of adolescent clients in a community

379 Pages·2016·2.59 MB·English

by  Jessica Riedel Chenoweth

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
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Chenoweth, Jessica Riedel, "Understanding dialectical behavior therapy through the voice of adolescent clients in a community mental
health center" (2014).Dissertations.Paper 236.
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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
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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