Towards the Development of an Effective Working Alliance: The Application of DBT Validation and Stylistic Strategies in the Adaptation of a Manualized Complex Trauma Group Treatment Program for Adolescents in Long-Term Detention

Although adolescent criminal behavior is multi-determined, one consistent finding is that 75% to 93% of youths entering the juvenile justice system annually “are estimated to have experienced some degree of trauma” (Adams, 2010). This is compared to 61.8% in a national sample of adolescents who were exposed to a potentially traumatic experience (McLaughlin et al., 2013). However, while only 4% of the general population develops post-traumatic stress disorder by age 18 years (PTSD), 26% to 45% of the incarcerated juvenile population fulfills DSM-IV criteria for this diagnosis (Merikangas et. al, 2010; Kerig et. al, 2009). These statistics suggest that youths in the juvenile justice system have not only been exposed to potentially traumatic events at a higher rate than their nondelinquent peers, but also are experiencing relatively more PTSD symptomatology. These statistics are supported by other researchers as well (e.g., Kerig, 2012).

Moreover, the trauma histories of juvenile offenders are often “complex” or “developmental” in nature, involving exposure to pervasive, longstanding, and ongoing trauma and extreme stress with attendant problems (e.g., behavioral and emotional dysregulation, cognitive distortions) that may not include core PTSD symptomatology, such as intrusive memories, thoughts, and feelings (Ford et al., 2012; Herman, 1992; van der Kolk, 2005, 2014). For these youths the often traumatic and stressful experience of detention can be even more damaging, and may increase their propensity for delinquent behavior after detention (Becker & Rickel, 1998; Kupers, 1996).

In light of the marked role of traumatic, extreme stress in the behavioral problems of serious juvenile offenders, it is clear that they need evidence-based, trauma-informed treatment programming (National Child Traumatic Stress Network, 2003). Although treatment in juvenile justice settings can be daunting, especially when resources for evidence-based mental health services are scarce, previous studies have shown that treatment for juvenile offenders can be beneficial. For example, mental health interventions reduce recidivism while punishment typically does not; in fact, punishment-based programs have been positively correlated with recidivism (Andrews & Bonta, 2010).

The co-therapists (the first two authors) were assigned to identify an evidence-based treatment to apply to a group of adolescent males with substantial, chronic trauma exposure histories in a detention facility located in a southeastern city of the United States. At the time, evidence-based treatments for this population were in the beginning stages of development. One such program that appeared promising was entitled Enhancing Resiliency: School-Based Group Treatment for Adolescents Living with Interpersonal Trauma (Kaplan et al., 2003). This treatment was particularly appealing for our setting because it was a unique and integrative, manualized group treatment approach. In fact, it was the only treatment available at the time specifically designed for adolescents living with interpersonal trauma, experiencing ongoing significant distress, and at risk for (or already experiencing) negative psychosocial outcomes consistent with the clinical concept of complex or developmental trauma referred to earlier. The manual by Kaplan et al. was developed by blending large elements of three established, evidence-based treatments: Dialectical Behavior Therapy (DBT; Linehan, 1993a, 1993b; Linehan, Armstrong, Suarez, Allmon & Heard, 1991; Linehan et al., 2006; Miller, Rathus & Linehan, 2007), Trauma Adaptive Recovery Group Education and Therapy (TARGET, Ford et. al, 2003), and UCLA’s Trauma/Grief Group Psychotherapy Program (Saltzman et. al 2006). Since our use of the initial version of the manual in the spring of 2005, the treatment has evolved further and has been renamed Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS; DeRosa, Habib, Pelcovitz, Rathus, Sonnenklar, Ford, et al., 2006; DeRosa and Pelcovitz, 2009). Because of this, as well as the fact that the goal of this paper is primarily to highlight relational strategies rather than the delivery of cognitive behavioral principles, we will refer to the treatment manual as “the Manual” for the remainder of the paper.

Before utilizing the Manual in our setting, we contacted the manual developers directly and asked for their permission to use and potentially adapt the manual for use with a population for which it was not directly intended; they gave us their permission and expressed an interest in learning how it worked with a youth population in detention (DeRosa, R., personal communication, December, 2004). Based on clinical experience working with complex trauma-exposed and behaviorally high-risk youths and adults in a variety of outpatient, restricted and forensic settings, multiple adaptations were made to the manual during treatment. Some of these changes proved to be particularly relevant to work with behaviorally disordered youths with complex PTSD histories.

In the remainder of this paper, we provide a clinical case example of how a manualized treatment for youths exposed to chronic stress was adapted to meet the needs of a group of detained male adolescents with a documented history of high levels of trauma exposure and related problems. More specifically, we highlight how acceptance-oriented and stylistically irreverent interventions consistent with dialectical behavior therapy principles were used to engage these youths authentically. Finally, we show that this initial, relationally-focused engagement process set the stage for the group members to self-initiate a therapeutic return to the exploration of the skills-based portions of the Manual as originally designed. Therapeutically poignant moments are interwoven as appropriate not only to punctuate the most salient clinical points we hope to make, but to also bring to life the underlying tone and “spirit” of the therapeutic process that the authors believe is essential for such authentic engagement to occur in such a population of youths.

The first one to two sessions were spent adhering relatively closely to the manual, which devoted two sessions to “Welcome and Introduction.” There were discussions and activities designed to orient members to the purpose of the group, and to develop group rules and rapport among participants and co-leaders. Almost immediately, the co-therapists realized that some changes were needed to enhance rapport establishment with this particular sample of youths, many of whom presented with significant symptoms consistent with conduct disorder and antisocial personality disorder. They were not interested in certain activities that they felt to be “hokey” or “pointless.” The following interaction illustrates this point:

In an effort to maintain the integrity of the manual while adapting the intervention to the needs of the particular group, the leaders proposed a more relationally authentic rapport-building activity. It entailed each group member identifying and verbalizing one good thing about the group member to their right; this activity was not only received well but spurred a great deal of discussion among the other group members. They all reported that none of them had heard directly how their peers positively perceived them.

As the manual existed at the time, the goal was to move past rapport building and developing group rules after session two in an effort to begin providing the group members with psychoeducation about the connection between trauma exposure and behavioral difficulties and how important it would be for their future to begin utilizing effective coping skills and tolerating distress effectively. However, it quickly became clear within two sessions of adhering to the manual that many of the adolescents were emotionally disengaged and were taking neither the content nor the co-therapists seriously. When the co-therapists paused the intervention in the middle of the third session to reassess what engagement activities were needed to proceed, a discussion was initiated by one group member. He focused on how the adolescents felt very “different” from their Caucasian, middle-class, professionally dressed, highly educated therapists. They did not think that the co-therapists could understand their lives or experiences, making the content being discussed irrelevant and impersonal. The therapists realized at this point that the structure of the manual during the initial sessions was not designed to address such large cultural discrepancies between therapists and group members. They also realized that the change/skills-orientation of the intervention, though theoretically well-grounded and clinically relevant, would not be effective, or even comprehensible, until a more authentic therapeutic alliance had been more firmly established between the co-therapists and the group members.

Approximately midway through the course of treatment (session 12 or so), substantial progress had been made concerning the development of the therapeutic relationship between the therapists and group members. The therapists had genuinely learned a substantial amount about the day-to-day experiences of group members, both while detained and “at home” in their families and communities. As discussed above, this had occurred through the predominant use of a variety of validation and acceptance-based strategies drawn from a DBT intervention framework. At this point, a notable shift began to occur, dictated exclusively by the group members rather than the clinicians. Specifically, they began to acknowledge that their past behavioral decisions had not always led to successful or positive outcomes but instead were often quite problematic. Additionally, they admitted without prompting that many experiences in their lives were, in fact, things they would never like to experience again. These types of acknowledgments would not have been possible in the early stages of treatment. As sessions continued, the adolescents were better able both to acknowledge the negative long-term outcomes of many of their maladaptive behaviors and creatively to generate more adaptive behavioral and cognitive alternatives (e.g., staying away from specific areas of their neighborhood, engaging in more pleasurable activities, attempting to consider pros and cons of behaviors in the moment). Opportunities began to arise for the clinicians to begin safely utilizing more of the psychoeducational, skill-building, and change-oriented strategies outlined in the manual. Because of the limited remaining course of treatment (approximately eight weeks), however, certain core concepts were retained while others were dropped. Core concepts presented and discussed during this middle phase of treatment from the manual were: 1) The impact of chronic stress and traumatic experiences on the body and mind, or “Unfinished Emotional Business;” 2) Concepts representing the balance between using logic and emotion in the decision-making process (i.e., “Reasonable Mind,” “Emotional Mind,” and “Wise Mind”); and 3) Developing the skills necessary for identifying and managing intense emotions (i.e., “Crisis Survival Skills”). These topics were always presented (a) in the context of the youths’ past and current difficult life histories, and (b) with the tone of clinician curiosity and ambivalence about whether the “information” being presented was at all relevant to the youths. It had the effect of strategically placing the therapists in a collaborative and, at times, deferential relationship with group members. The group had the authority to determine whether the information might be useful in their lives. Examples used to frame these concepts were rarely provided by the therapists but were elicited from the youths whenever possible to ensure that the discussion context remained ecologically valid and relevant to group members. While the focus shifted to problem-solving, skill-building, and general change-oriented frameworks, a much higher proportion of DBT-based irreverence, validation, and acceptance-based interventions continued to be used. This was more than was suggested in the original manual or than might be otherwise thought necessary by clinicians unaccustomed to treating adolescents who met criteria for conduct disorder and who had initial nonverbal presentations as unemotional and relationally disconnected. A paraphrased interaction during this phase highlights the challenge for the therapists to balance acceptance and change-oriented strategies with this population of youths even once therapeutic rapport was established. It was especially difficult when morally complex and psychologically intense behavioral content were discussed:

As members of the treatment group poignantly reminded us, authentically engaging youths with a history of repeated, pervasive trauma and conduct disorder on a human level is essential, albeit often challenging. Given the past behaviors, sometimes intimidating interpersonal presentations, and profound distrust of this group, we found that engagement is greatly facilitated by using acceptance-oriented strategies (such as those in DBT) to maintain high clinical attunement to the therapeutic alliance throughout treatment. We posit that these interventions are necessary, regardless of the specific clinical framework or therapeutic modality being used.

Although authentic human engagement was a necessary component of this treatment course, this factor alone was not sufficient to explain the clinical movement seen and described in this particular clinical case example. Skills-based, change-oriented approaches were also necessary and were explicitly and spontaneously requested by the youths once the alliance had been established. The youths with whom we worked presented with substantial skills deficits across a variety of psychosocial and behavioral domains, such as emotion dysregulation, reduced sense of identity and life meaning, behavioral impulsivity, and significant prosocial skills deficits, which were consistent with a complex or developmental trauma framework. Without implementing skills-based treatment components, these youths would have developed no new psychological or behavioral tools for managing their extremely challenging lives both during and after detention.

Although many evidence-based treatments inherently focus on change, very few of these treatment manuals have actually elaborated on how critical acceptance and validation strategies are to the facilitation of such change. In the last two decades, more empirically-supported treatments have begun to formally acknowledge the importance of balancing change with acceptance-based strategies, including Dialectical Behavior Therapy (Linehan, 1993a), Motivational Interviewing (Miller and Rollnick, 2012), and Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 2011). We encourage clinical researchers, especially those who work with multi-problem clients and adolescents, to continue to attend to and refine acceptance-based strategies for their use in all stages of treatment.

Finally, research identifying effective interventions for behaviorally disordered youths who have complex PTSD and are in restricted settings is greatly needed. We posit that one possible starting point for such research should be adaptations of existing, empirically informed or empirically-supported treatments, such as SPARCS and DBT. We recommend the incorporation of principle-driven guidelines and relationally based clinical markers for the establishment of a strong working therapeutic alliance prior to moving into primarily change and skills-oriented treatment phases of these existing interventions. However, other creative approaches should also be explored.

A member of the juvenile detention staff reported to the co-therapists that the group member who stated, “you helped me feel again,” was stabbed in the chest at a party and nearly killed just a few weeks after being discharged from juvenile detention. Solutions to the problem of how to effect meaningful change with youths such as the young men described in this paper cannot arrive fast enough. Without purposeful and urgent attention, young men like those described in this paper, who are some of the most marginalized, traumatized, and socially costly youths in our country, will remain inadequately treated and will have little hope of meaningful re-entry into mainstream society.