Dialectical Behavior Therapy for Suicidal Latina Adolescents: Supplemental Dialectical Corollaries and Treatment Targets

In 2011, the Youth Behavior Risk Surveillance System found that 21% of Latina adolescent females seriously considered a suicide attempt (SA) during the past 12 months and 14% had engaged in at least one suicide attempt (Centers for Disease Control and Prevention). These SA rates were higher than those for African-American (8.8%) and Caucasian-American adolescent females (7.9%). At Montefiore Medical Center’s Adolescent Depression and Suicide Program in the Bronx, NY, the majority of patients are Latina adolescents. Our team conducted studies with Latina adolescents, parents, and treating clinicians with the goal of improving our treatment protocol for this high-risk group (Germán, González, & Rivera-Morales, 2013; Germán, Haaz, Haliczer, Bauman, & Miller, 2013).

A promising treatment for Latina adolescents who are suicidal is dialectical behavior therapy (DBT), an evidence-based treatment originally developed for adults with borderline personality disorder (BPD) who were chronically suicidal (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan et al., 2006; Van den Bosch & Verheul, 2007; Verheul et al., 2003). Dialectical behavior therapy was adapted for use with teens by Rathus and Miller (2002). Studies comparing DBT to treatment-as-usual conditions have shown promising results in reducing deliberate self-harm behavior, psychiatric hospitalizations, suicidal ideation, depression, hopelessness, and borderline personality disorder symptomatology (Mehlum et al., 2014; Rathus & Miller, 2002).

Marsha Linehan (1993) proposed that individuals who engage in suicidal and nonsuicidal self-injurious behaviors (NSSI) with a diagnosis of BPD often resort to extreme behavioral patterns, which are referred to in DBT as dialectical dilemmas. When these patterns occur, the individual shifts between polarized behavioral extremes in an effort to regulate his or her emotional state. However, these patterns are ineffective and often function to over or under regulate the individual’s emotions and behaviors, and are thus deemed as “dialectical failures.” Accordingly, Linehan (1993) developed treatment targets to find a synthesis between the extreme behavioral styles by decreasing these maladaptive behaviors (e.g., active passivity, apparent competence, self-invalidation) and increasing adaptive behaviors (e.g., active problem solving, effectively asking for help, and self-validation). See Linehan (1993) for a full review of the original DBT dialectical dilemmas.

In working with adolescents who have multiple problems and BPD features, Miller, Rathus, and Linehan (2007) described additional extreme behavioral patterns that were transactional in nature and occurred between the adolescent and his or her environment. They identified three dialectical dilemmas specific to working with adolescents and their parents (i.e., excessive leniency versus authoritarian control, normalizing pathological behaviors versus pathologizing normative behavior, and fostering dependence versus forcing autonomy). These dialectical dilemmas have been helpful to conceptualize adolescents’ and their parents’ problematic behavioral patterns and to further formulate appropriate treatment targets.

Based on our research findings and clinical observations of Latina adolescents and families, the current authors expand upon the existing adolescent dialectical dilemmas by proposing supplemental dialectical corollaries frequently observed in Latino families. We first review the existing adolescent/family dialectical dilemmas, and then discuss the dialectical corollaries. Our goals are to provide additional interpretations of the adolescent dilemmas to foster a better understanding of the extreme behavioral patterns that can manifest in Latino families and better inform our treatment targets and strategies.

Old school refers to an extreme parenting style in which parents have a rigid and inflexible adherence to the norms by which they were raised, typically stemming from their country of origin. These norms include expectations about age-appropriate behaviors, values, parenting practices, and parent-child interactions. Even when Latino parents were raised in the U.S.A., they often adhere strictly to the norms of their immigrant parents³. Previous research has shown that traditional Latino families have some norms about parenting practices, parent-child interactions, and values that differ from U.S. norms. For example, Latino children are expected to exhibit high degrees of control over their behaviors, particularly in public, and normative parental discipline practices often include the use of physical restraint or corporal punishment (Barker, Cook, & Borrego, 2010; Calzada, 2010). Researchers have also found Latino families more strongly emphasize adolescents’ duty to take care of younger siblings compared to Caucasian families (Fuligni & Pedersen, 2002). One cultural value that holds great magnitude in Latino families is respeto (i.e., respect). In general, the value of respeto places a greater emphasis on obedience compared to the American value of “respect” (Andres-Hyman, Ortiz, Anez, Paris, & Davidson, 2006).

Clearly, it is important for clinicians to assess the extent to which the Latino parents they work with adhere to these traditional norms and to not make assumptions about parents’ values and behaviors. The research conducted in our clinic with our Latino population has highlighted the importance placed on the value of respeto in the parent-adolescent relationship (Germán et al., 2013a). Specifically, we observed that adolescents were taught not to question, argue, or negotiate with their parents given that this manner of interaction was deemed disrespectful when the parents were growing up. For parents who adhere to these old-school Latino norms, violation of these expectations by their teenagers is perceived as deviant within the family system, unacceptable to the parents and extended family members, and perceived as potentially dangerous by the parents especially if families live in high-crime neighborhoods.

The old-school pole may also involve significant influence from extended family members. Some Latino parents report getting criticized for not being able to properly control their adolescent’s behavior or for having their teenager receive mental health treatment. Parents consequently report feeling shamed by their extended family. This judgment often leads parents to keep their parenting struggles to themselves and/or to not participate in their adolescent’s treatment. As such, deviation from old school values may result in the Latino parents’ development of cognitive distortions of themselves as “weak” or a “failure”.

We propose that strict adherence to the old-school pole may be one contributing factor in the development of the dialectical behavior pattern called authoritarian control. As noted previously, parents that manifest this extreme parenting behavior stifle their adolescent’s increasing desire for autonomy, and apply excessive punishments or other methods to exert control. Based on clinical research (Germán et al., 2013a, 2013b), we find that parents of suicidal, Latina adolescents often limit their teen’s autonomy before they started engaging in self-harm behavior (e.g., many of our Latina adolescents reported being unable to participate in after-school activities, go to the park or store after school with friends, attend non-family parties, or date). Latino parents often expressed the belief that their parenting behaviors were normative, considering what was typical of the time and place they were raised. Researchers have reported that in Puerto Rico, the Dominican Republic, and other Latino countries from which the families in our program immigrated, alternative social structures and practices enabled adolescents to socialize with peers (i.e., large extended family networks); yet in the process of immigrating to the U.S.A., these networks often were lost (Kulberg et al., 2010; Peña et al., 2011).

New school sits opposite old school in this dialectical corollary, and refers to a rigid adherence to the current era and the dominant culture’s norms, values, parenting practices, and parent-child interactions. Latina adolescents in our program typically fall at this end of the continuum. Whereas the old-school pole involves the influence of extended family members, the new-school pole involves influence from peers, teachers, and the media in the U.S.A. Latina teenagers who attend American schools have more exposure to and contact with the social mores of dominant culture compared to their parents, who may continue to have much less exposure. In contrast to the traditional Latino norms described previously, normative behaviors for teenagers in America include a mild-to-moderate degree of negotiations with parents, and a parental tolerance for increased argumentativeness, dating, attending parties and sleepovers (Steinberg, 2005).

Latina adolescents within our studies often compared their lives to that of their peers, many of whom were also Latina but came from more acculturated families in which they were granted more autonomy (Germán et al., 2013a). Latina teens often expressed that their parents “should” allow them more liberties (e.g., attend parties with peers, have the same [later] curfew as peers, etc.) When adolescents were not granted these privileges, they often felt they had the right to question and repeatedly negotiate with their parents, as they had observed these interactions between their friends and their parents. Consequently, many of our Latina teens would engage in these restricted and forbidden behaviors (such as dating) in secret. We propose that this friction in beliefs and values lead parents and adolescents to both feel disrespected and invalidated, thereby increasing their levels of parent-teen conflict. Over a period of months or even years, this conflict became chronic. The resulting tension, coupled with the adolescents’ deficits in emotion regulation, was found to frequently precipitate the teens’ suicidal behaviors as a means to temporarily escape their uncomfortable negative emotional states. This behavior often further reinforced the polarization between parents and their adolescents, frequently causing the frightened parents to adopt an even stricter parenting regimen. Therefore, this old school manifestation exists as both a precipitant and consequence of the adolescent’s suicidal behaviors.

Clinicians sometimes inadvertently enter into these polarities as well. Many of our Latina adolescents disobeyed their parents’ strict orders in order to conform to the new school norms. While keeping such violations from their parents, they would disclose their behaviors to their clinicians (Germán et al., 2013b). In turn, some clinicians described how they developed a “secret keeper” role (i.e., trying to maintain the therapeutic relationship and the adolescent’s confidentiality by withholding information from parents, yet attempting to attend to parental concerns and improve parent-adolescent communication). This dilemma was often further complicated by clinicians feeling pulled to one end or the other of the old school versus new school continuum due to their own generational and cultural background.

Based on standard adolescent DBT protocol (Miller et al., 2007), clinicians understandably spend more time listening to and validating the adolescent’s view in individual sessions. Therefore, the therapist may feel more empathic and prone to reinforce the adolescent’s new school ways. The clinician must be careful to “honor the old school ways” and validate the parents’ concerns when working towards a synthesis to resolve conflict between the parents and adolescent; otherwise, parents may feel invalidated. This sense of parental invalidation may further strengthen their polarized positions, often resulting in a therapeutic impasse.

Both overprotecting and underprotecting poles appear to be related to a subset of Latino parents who had exposure to abuse or near death experiences that had critical consequences for their parenting behaviors. We use the phrase “history of trauma” to indicate experiences of sexual, physical, or emotional abuse or threat of a near-death experience or serious injury when the parents themselves were children or adolescents. These distressing experiences may have resulted in the development of trauma symptoms, which in turn may have shaped their perceptions of the world as “unsafe” or “unfair” and prompted the development of one of these two extreme patterns of cognitive and behavioral responses.

Overprotecting refers to an extreme style in which parents maintain a rigid and inflexible adherence to the notion that the world is an unsafe and dangerous place. This notion informs the overprotecting parents’ perceptions that granting their adolescent more autonomy or freedom to explore the outside world is potentially life-threatening. This often stems from the parents’ history of trauma. These parents become overwhelmed by feelings of intense worry and consequently are very restrictive in their provision of what is allowed versus what is not allowed in terms of their adolescent’s behavior. They also often cite their own experience of trauma as “evidence” or “justification” of their overprotecting parenting behaviors. The adolescent’s failure to comply with these stringent rules typically result in the excessive punishment seen in the original dialectical parenting pattern of authoritarian control.

Overprotecting parents tend to be unresponsive and sometimes defensive toward clinicians’ efforts to introduce supervised, normative activities into the adolescent’s life. For example, a clinician may prompt overpro-tecting parents to consider compromising with the adolescent by allowing her to spend time with friends after school as long as an adult supervises them. Parents may still insist that this is an unacceptable request because they cannot trust any non-familial adult to provide appropriate supervision (e.g., the parents refuse to permit the adolescent to join the school track team). Parents that retain this overprotective stance do not consider their concerns to be disproportionate to the risk involved; consequently, they may feel invalidated by the clinician’s and adolescent’s attempts to negotiate. Accordingly, these parents find it difficult to implement the specific DBT skills of validation and perspective taking. We propose that parents’ sense of ubiquitous danger may be triggering them to respond in this unreceptive and inflexible manner. On this end of the continuum, parents view their adolescent as vulnerable and lacking the capacity to keep themselves safe.

Opposite the overprotecting pole exists the underprotecting pole, which refers to an extreme view of the world as being inherently unfair and unjust. Parents at this extreme often ruminate about their difficult childhoods, incessantly focusing on their own suffering and pain, and they tend to compare their past anguish and own painful memories of abusive or even traumatic experiences to those of their currently suicidal adolescent. Social psychologists describe this process as downward social comparison in which individuals in unfortunate circumstances attempt to enhance their subjective well-being through comparison with seemingly less fortunate others (Wills, 1981). These underprotecting parents consequently engage in minimization and invalidation of their teen by considering their adolescent’s life to be “not as bad,” and perhaps even notably better than their own childhood. They often explicitly verbalize these thoughts to their adolescent and the treating clinician. Statements such as “she’s ungrateful for her better life,” or “she doesn’t get the sacrifice I’ve had to make to raise her” are typical among this subset of parents. In this scenario, the adolescent appears to serve as a constant reminder or symbol of an unfair world or of the parents’ past abusive relationships. This pervasive invalidation of the teen often leads the teenager to shut down, feel misunderstood, and creates unjustified feelings of shame, self-invalidation, and increasing emotional and behavioral dysregulation.

Underprotection may be manifested by the parents’ minimization of the danger surrounding their adolescent’s current suicidal ideation and past suicidal behaviors. Even with the knowledge of their adolescent’s previous attempts to overdose or engage in nonsuicidal self-injurious behaviors, parents at this pole may not take the precautionary steps as directed by the clinician to keep their adolescent safe by locking up medications and sharp objects. Underprotection may also involve parental refusal (or minimal or ambivalent) participation in the adolescent’s treatment.

Another aspect of this dialectical corollary includes parents burdening their adolescent with adult-like responsibilities that often appear similar to the dialectical dilemma forcing autonomy. Rathus and Miller (2000) posit that parents at the forcing autonomy pole sever or loosen ties with their adolescent because they feel either overwhelmed by their teen’s suicidal behaviors or they want to push their teen to mature more quickly. We hypothesize that parents who underprotect engage in forcing-autonomy type behaviors with their teen because they are motivated by their own extreme childhood experiences of abuse or trauma. For example, at the underprotecting pole, parents burden their adolescents with duties that are partially similar to those imposed on them as children (e.g., excessive caretaking of younger siblings, tending to the household). This parallel is demonstrated by one parent’s statements, “When I was 14-years-old, I had to take care of all my siblings, clean the house every day, and cook so I couldn’t spend time with my friends.” Within this scenario, these enforced responsibilities on the teen are different enough from the parents’ own as a child that they are communicated to the adolescent as “easier” and hence fair. Thus, while the parenting behaviors in both the forcing autonomy dialectical dilemma and the underprotecting corollary may present in a similar fashion, the motivations underlying the parental behavior differ, and therefore, should have different treatment targets.

This paper described the dialectical corollaries we frequently observed in treating Latina adolescents who were suicidal and their families. Old school versus new school encapsulates extreme behaviors fueled by norms of the parents’ country of origin clashing with the adolescent’s adaptation of norms present in the current environment. Overprotecting versus underprotecting represents extreme parenting behaviors that stem from early parental exposure to trauma. The suggested treatment targets focus on enhancing mindfulness skills, validation, dialectical thinking, and correcting cognitive distortions. We have also outlined suggestions to help clinicians manage therapeutic impasses (i.e., dialectical failures).

It is important to note that the dialectical corollary of old school versus new school may be present in other immigrant dyads. Additionally, the dialectical corollary of overprotecting versus underprotecting may apply to parents from other cultural backgrounds that experienced similar histories of trauma. We hope that the aforementioned dialectical corollaries and proposed treatment targets and techniques will enhance the standard adolescent DBT protocol and improve outcomes among suicidal, Latina teenagers and their families.

The authors wish to thank Elizabeth Courtney-Seidler, PhD, for her help in reviewing the manuscript.