Counseling Outcome Research

Counseling Outcome Research

and Evaluation
Emotional Regulation 2016, Vol. 7(2) 73-85
ª The Author(s) 2016
and Interpersonal Effectiveness Reprints and permission:
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DOI: 10.1177/2150137816642439
as Mechanisms of Change for core.sagepub.com

Treatment Outcomes Within

a DBT Program for Adolescents

A. Stephen Lenz1, Garry Del Conte2,

K. Michelle Hollenbaugh1,
and Karisse Callendar1

Abstract
Predictive modeling was used to identify the degree that hypothesized moderators of dialectical
behavioral therapy for adolescents (DBT-A) treatment outcomes predicted anxiety and depression
symptoms over time. Participants were 66 adolescents (41 girls; 25 boys) with a mean age of 15.38
years (SD ¼ 1.51) who completed a 7-week DBT-A intervention. Analyses revealed convergent
models, wherein emotion regulation and interpersonal effectiveness were substantial predictors
of change in the symptoms of anxiety, F(4, 65) ¼ 23.21, p < .01, R2 ¼ .60, and depression,
F(4, 65) ¼ 29.76, p < .01, R2 ¼ .66.

Keywords
adolescents, DBT, emotion regulation, interpersonal effectiveness, outcomes

Dialectical behavior therapy (DBT) was origi- positive findings, the application of DBT has
nally developed several decades ago for the grown significantly, and researchers have
treatment of borderline personality disorder and applied this intervention to transdiagnostic
is considered one of the most effective inter- populations, including those afflicted with
ventions for treating this population (Linehan,
2015). Researchers have conducted several ran-
domized controlled trials and found that DBT is 1
Texas A&M University–Corpus Christi, Corpus Christi,
effective not only in reducing emotion dysre- TX, USA
2
gulation but also in increasing coping skills Daybreak Treatment Center, Germantown, TN, USA
(e.g., Linehan et al., 2015; Verheul, van,
Submitted October 21, 2015. Revised March 11, 2016.
Koeter, de Ridder, Stijnen, van, 2003). Further, Accepted March 11, 2016.
one neurologically based study found that par-
ticipants who engaged in DBT actually experi- Corresponding Author:
A. Stephen Lenz, Early Childhood Education Center, Texas
enced noticeable reductions in emotion A&M University–Corpus Christi, Room 152, Corpus Christi,
dysregulation via reduced amygdala reactivity TX 78412, USA.
(Goodman et al., 2014). As a result of these Email: stephen.lenz@tamucc.edu
74 Counseling Outcome Research and Evaluation 7(2)

eating disorders, anxiety disorders, and mood self-injury (Ritschel, Miller, & Taylor, 2014).
disorders (Lenz, Taylor, Fleming, & Serman, This includes those struggling with bipolar dis-
2014; Lynch, Morse, Mendelson, & Robins, order (Goldstein, Alexson, Birmaker, & Brent,
2003; Neacsiu, Eberle, Kramer, Wiesmann, & 2007), eating disorders (Salbach-Andrea,
Linehan, 2014). Bohnekamp, Pfeiffer, Lehmkuhl, & Miller,
Pervasive emotion dysregulation plays a sig- 2008), and oppositional defiant disorder
nificant part in the etiology and symptomology (Nelson-Gray et al., 2006). Researchers have
of these diagnoses, and therefore researchers also adapted DBT to fit different settings. For
have argued that DBT is well suited for the example, Ricard, Lerma, and Heard (2013)
treatment of these disorders (Neacsiu, Bohus, applied DBT in an alternative school setting
& Linehan, 2013). This reasoning is in accor- and found that participants reported reduced
dance with the biosocial theory of DBT (Line- distress compared to those who did not engage
han, 2015), which explains that pervasive in the DBT group. In another study, Wasser,
emotion dysregulation is the result of two inter- Tyler, Mcllhaney, Taplin, and Henderson
acting factors—a biological predisposition to (2008) examined DBT in a residential setting
emotional vulnerability and a persistently inva- and found that DBT resulted in more statisti-
lidating environment. Linehan and Neacsiu cally significant positive changes than the stan-
et al. noted that both of these factors promote dard therapeutic milieu alone.
development of the pervasive emotion dysregu-
lation that is related to numerous mental health
disorders. In addition to the use of this modality Hypothesized Mechanisms
with different diagnoses, researchers have
of Change Within DBT for
adapted DBT for use with adolescents (Miller,
Rathus, & Linehan, 2007). There is a strong Adolescents
theoretical basis for using this intervention with There are four treatment targets during the first
adolescents, as they have reached the develop- stage of treatment: decreasing life threatening
mental milestone during which they are learn- behaviors, decreasing therapy interfering beha-
ing to effectively and independently manage viors, decreasing quality of life interfering
their emotions (MacPhearson, Cheavens, & behaviors, and increasing behavioral skills
Fristad, 2013). (Miller et al., 2007). These targets are
Adaptations to standard DBT for adolescents addressed through the implementation of sev-
maintain the fidelity of the treatment by retain- eral modes of treatment, including skills groups
ing all of the original modes and stages of treat- and individual sessions. However, researchers
ment as well as related treatment targets. The (Linehan & Wilks, 2015; Valentine, Bankoff,
changes made by practitioners compliment the Poulin, Reidler, & Pantalone, 2015) have found
specific needs of adolescents. Family members that treatment targets can be addressed through
are included in skills groups, and skills modules the intentional application of select modes of
are often offered for shorter periods of time (ses- treatment, as opposed to all of them. In order
sion and module length). In addition, developers for DBT to be effective, treatment should be
included family therapy sessions as needed and flexible enough to allow for changes to content
modified skills for increased comprehension. and clinical focus as needed but also structured
Finally, an additional skills module, walking the with a hierarchy of skills development occur-
middle path, was added to teach the concept of ring across DBT-A modules.
validation, dialectics, and behaviorism (Miller Clinicians most often address the treatment
et al., 2007). target increasing behavioral skills through the
Researchers have found positive results in implementation of the psychoeducational skills
studies applying these modifications of DBT group. There are five modules outlined in the
transdiagnostically to adolescents in addition adolescent skills training manual that are
to those who exhibit suicidality and nonsuicidal hypothesized as mechanisms of change within
Lenz et al. 75

a DBT framework, specifically for adolescents sections: reaching goals, making and maintain-
(DBT-A): mindfulness, distress tolerance, ing relationships, and maintaining self-respect.
interpersonal effectiveness, emotion regulation, The core skills, included in the first section,
and walking the middle path (Rathus & Miller, include teaching effective strategies for setting
2015). boundaries and making assertive requests. In
the second section, individuals learn how to
develop and maintain positive family, friend,
Mindfulness and community relationships. Finally, in the
Drawn from Zen practices that are compatible third section, adolescents learn to cultivate
with Eastern meditation, mindfulness practice is self-respect by being fair, truthful, and faithful
considered by Linehan and colleagues to be one to their values. These skills teach individuals to
of the core skills in DBT. Mindfulness is often consider the complexity of relationships and
the first module taught, and it is then reviewed cultivate awareness of acceptance, flexibility,
again at the beginning of each of the other mod- and change while improving collaboration and
ules. Individuals practicing mindfulness skills communication (Rathus & Miller, 2015).
effectively observe, describe, and participate in
the present moment without judgment and with
the intent to be both effective and one mindful.
Emotion Regulation
The purpose of mindfulness in DBT is to culti- Emotion regulation skills are taught in the con-
vate nonjudgmental attention to the present text of self-validation of emotions and require
moment for the purpose of activating and main- the application of mindfulness skills. In this
taining wise mind. Wise mind is a core DBT-A module, adolescents learn how to name and
concept that is used in the service of helping identify emotions, learn how emotions are trig-
adolescents control their state of mind by repeat- gered, and become aware of the associated bod-
edly seeking a dialectical synthesis between rea- ily sensations that give rise to various thoughts
son and emotion (Linehan, 2015). and action tendencies. Individuals learn tactics
to problem solve and change both emotions
using skills like cope ahead, opposite action,
Distress Tolerance and riding the wave (Linehan, 2015).
The goal of this module is to teach adolescents
how to tolerate strong dysregulated emotions
when immediate solutions to prompting events Walking the Middle Path
are not readily available. This includes learning This module was developed specifically for
how to bear pain in a skillful way, without adolescents and includes didactic information
making matters worse. These skills are a natu- about dialectical thinking and problem-
ral progression from the mindfulness module solving strategies, principles of behaviorism
and are grouped into two components during that promote changes of their behavior, and use
treatment. The first component focuses on tol- of validation to improve communication and
erating short-term crisis and relying on distract- strengthen relationships (Miller et al., 2007).
ing or self-soothing activities. The second Throughout this module, adolescents learn to
component involves a more conceptual skill set replace either-or thinking and dichotomous
that teaches the ideas of willingness and radical appraisals of choice options with a more plur-
acceptance for more enduring life challenges alistic view of possible reactions to the prob-
like the loss of a loved one (Linehan, 2015). lems they encounter. In outpatient adolescent
treatment, the middle path skills may be taught
as a separate module either in multifamily
Interpersonal Effectiveness group or in parallel adolescent and parent
This module focuses on teaching adolescents groups. However, developers of DBT-A have
relationship skills and is divided into three posited that skills can be taught in different
76 Counseling Outcome Research and Evaluation 7(2)

formats and arrangements as the clinician sees Method

fit to help the adolescents best learn the skills
We implemented a secondary analysis of data
(Rathus & Miller, 2015). In the current study,
from a single group, open trial of DBT-A (Del
the middle path skills were included as a sub-
Conte et al., in press) to identify the degree that
component of the interpersonal effectiveness
the intervention’s hypothesized mechanisms of
module utilizing parallel adolescent and parent
change were associated with treatment gains
groups. This was done to increase the general-
across ANX and DEP symptom domains.
ization of the skills in both modules.

Purpose of the Study Participant Characteristics

There have been very promising initial results Participants were 66 adolescents (41 girls,
regarding treatment outcomes with adoles- 62%; 25 boys, 38%) referred from their com-
cents; however, researchers have called for fur- munity with a mean age of 15.38 years
ther research on the use of DBT with this (SD ¼ 1.51) who were completing a 7-week
population (Del Conte, Lenz, Hollenbaugh, & manualized DBT-A intervention at a partial
Callendar, in press; MacPhearson et al., 2013). hospitalization program (PHP) located in the
Little evidence has emerged identifying the mid-southern region of the United States. Par-
degree that supposed mechanisms of change ticipants were predominately White/Caucasian
appear to predict treatment outcomes for (n ¼ 58; 89%) with others identifying as either
adolescents, especially in affiliation with trans- Black/African American (n ¼ 2; 3%) or Other
diagnostic applications. Therefore, we imple- (n ¼ 6; 9%) ethnic identities. Participants met
mented regression modeling to depict the the Diagnostic Statistical Manual of Mental
degree that changes among hypothesized Disorders, Fourth Edition, Text Revision
mechanisms of changes within DBT-A were (American Psychiatric Association, 2000) diag-
associated with treatment gains among a trans- nostic criteria for a primary diagnosis of a
diagnostic population over time. As a result, we depressive disorder (n ¼ 17, 35%); bipolar dis-
undertook this analysis to answer two research order (n ¼ 11, 23%); and mood disorder, not
questions: (a) to what degree do changes among otherwise specified (n ¼ 10, 21%); ANX dis-
the hypothesized mechanisms of change within order, not otherwise specified (n ¼ 3; 6%); dis-
a DBT framework (emotional regulation, inter- ruptive mood dysregulation disorder (n ¼ 3;
personal effectiveness, distress tolerance, and 6%); attention deficit hyperactivity disorder
mindfulness) predict changes in ANX symp- (n ¼ 3; 6%); and obsessive-compulsive disor-
toms following a 7-week DBT-A program? and der (n ¼ 1; 2%).
(b) to what degree do changes among the
hypothesized mechanisms of change within a
DBT framework (emotional regulation, inter-
Measurement of Constructs
personal effectiveness, distress tolerance, and ANX and DEP. We used scores on the ANX and
mindfulness) predict changes in depression DEP subscales of the Symptom Checklist
(DEP) symptoms following a 7-week DBT-A 90-revised (SCL; Derogatis, 1994) to identify
program? We selected therapeutic criterion participants’ subjective perceptions of ANX
related to ANX and DEP based on participant and DEP. ANX and DEP subscale items are
characteristics of this transdiagnostic sample administered in a self-reported, Likert-type for-
whose diagnoses included behavioral criterion mat that assess frequency and severity of symp-
representative of DEP and ANX either indepen- toms along a continuum ranging from 0 (not at
dently or concurrently. Constructs related to all) to 4 (extremely).
walking the middle path were not included in The ANX subscale is comprised of 10 items
our predictive model due to the absence of that evaluate general markers of ANX includ-
related assessments within the research protocol. ing nervousness, tension, apprehension, dread,
Lenz et al. 77

and somatic correlates that are appraised with validity with the Negative Mood Regulation
prompts that include ‘‘the feeling that some- Scale (Catanzaro & Mearns, 1990).
thing bad is going to happen to you’’ and ‘‘ner-
vousness or shakiness inside’’ with higher Interpersonal effectiveness. We used the Interper-
scores indicating greater subjective ANX. sonal Sensitivity (INT; Derogatis, 1994) Scale
Derogatis (1994) reported robust internal con- from the SCL to assess participants’ abilities to
sistency (a ¼ .88) and test–retest (rtt ¼ .86) manage relationships via processes associated
reliability coefficients for scores on the ANX with interpersonal effectiveness. The INT sub-
subscale as well as acceptable convergent scale is comprised of 10 items that evaluate
validity with other related measures. Within general markers of interpersonal behavior
our sample, internal consistency was within the including self-doubt, discomfort when inter-
excellent range (a ¼ .94). The DEP subscale acting with others, and negative expectations
includes 13 items that evaluate markers of DEP when interacting with others that are
including dysphoric mood, social withdrawal, appraised with prompts that include ‘‘feeling
lack of motivation, and hopelessness that are inferior to others’’ and ‘‘feeling very self-
assessed using items such as ‘‘feeling hopeless conscious with others’’ with higher scores
about the future’’ and ‘‘feeling no interest in indicating greater interpersonal sensitivity.
things’’ with higher scores indicating greater Derogatis reported good internal consistency
subjective DEP. Derogatis (1994) reported (a ¼ .86) and test–retest (rtt ¼ .83) reliability
robust internal consistency (a ¼ .90) and coefficients for scores on the INT subscale as
test–retest (rtt ¼ .82) reliability coefficients well as satisfactory convergent validity with
for scores on the DEP subscale as well as satis- other associated measures. Internal consis-
factory convergent validity with other associ- tency within our sample was within the excel-
ated measures. Within our sample, internal lent range (a ¼ .91).
consistency was within the excellent range
(a ¼ .93). Distress tolerance. The DBT Ways of Coping
Checklist (WCCL; Neacsiu, Rizvi, Vitaliano,
Emotion regulation. The Difficulties in Emo- Lynch, & Linehan, 2010) was developed to
tional Regulation Scale (DERS; Gratz & Roe- provide an objective measure of DBT skills use
mer, 2004) was developed to assess degrees of as distress tolerance activities and is composed
emotional dysregulation across six domains of three subscales: Skills Use, General Dys-
including nonacceptance of emotions, difficul- functional Coping, and Blaming Others. For
ties engaging in goal directive behavior, our study, we used scores on the Skills Use
impulse control difficulties, lack of emotional subscale as an indication of participant
awareness, limited access to emotion regulation actions to accept and mitigate distressing
strategies, and lack of emotional clarity. The events. The Skills Use subscale (WCCL-
36-item DERS provides a self-reported, Skills Use) is composed of 38 items presented
Likert-type format with responses to items such in a self-reported, Likert-type format with
as ‘‘when I’m upset, I lose control over my responses to items such as ‘‘came up with a
behaviors’’ and ‘‘I am attentive to my feelings’’ couple of different solutions to my problem’’
ranging from 1 (almost never) to 5 (almost and ‘‘concentrated on something good that
always). The mean score within each domain could come out of the whole thing’’ ranging
is totaled to provide an overall metric of parti- from 0 (never used) to 3 (regularly used).
cipants’ degree of emotional regulation with Neacsiu et al. reported excellent internal
higher scores indicating greater ability to reg- consistency for the WCCL-Skills Use across
ulate emotions. Gratz and Roemer reported multiple studies (a ¼ .92–.96) and good con-
excellent internal consistency for total DERS vergent validity with related measures. Inter-
scores (a ¼ .92) which was corroborated within nal consistency within our sample was within
our sample (a ¼ .90) and substantial construct the excellent range (a ¼ .94).
78 Counseling Outcome Research and Evaluation 7(2)

Mindfulness. The Freiburg Mindfulness Inven- and included Schedule 6: Adolescent Multi-
tory (FMI; Walach, Buchheld, Buttenmuller, family Skills, Schedule 9: DBT Parenting Skills
Kleinnecht, & Schmidt, 2006) was developed Behaviors, and selections from Schedule 8:
to estimate an individual’s ability to experience DBT Skills for Addictive Behaviors. During
moments accurately without the influence of the 7-week program, all participants completed
emotional or intellectual distortion. The skills training across all five DBT modules
14-item FMI provides a self-report, Likert- (mindfulness, emotion regulation, distress tol-
type format for responses to items such as ‘‘I erance, interpersonal effectiveness, and walk-
feel connected to my experience in the here- ing the middle path). Participants completed
and-now’’ and ‘‘I watch my feelings without home tasks with their parents that taught skills
getting lost in them’’ ranging from 1 (rarely) to foster a protreatment atmosphere at home
to 4 (almost always) with higher scores indicat- and provided an opportunity to demonstrate
ing greater mindfulness. Walach, Buchheld, skillful behavior in the presence of their par-
Buttenmuller, Kleinnecht, and Schmidt (2006) ents. During daily closure groups, participants
reported good internal consistency for scores developed a goal sheet for the following 24-hr
on the FMI across studies (a ¼ .86) and strong period and set a behavioral objective for that
convergent validity with other related mea- evening.
sures. Internal consistency within our sample
was within the good range (a ¼ .85).
Procedure
The current data are associated with the pri-
Intervention mary analysis of a DBT-A PHP evaluation
A complete description of milieu-based partial described by Del Conte, Lenz, Hollenbaugh,
hospital DBT for adolescents (DBT-A) is pro- and Callendar (in press). All participants com-
vided in Del Conte et al. (in press). Within this pleted treatment in the 7-week PHP during
framework, planned group modalities include a which the admission process required comple-
daily opening and closing group, problem- tion of SCL, DERS, WCCL, and FMI which
solving process group, and DBT skills training was again completed during a discharge inter-
group. A regular DBT family skills group com- view. The 7-week duration of the program was
pliments individual DBT psychotherapy once established based on clinical experience of the
or twice weekly during the program. Partici- program coordinator and the assumption that a
pants also simultaneously complete course cur- minimum of 35 DBT-A lessons were required
riculum in a state-approved educational to achieve desired therapeutic effect. PHP staff
program, and a psychiatrist supervised all med- entered all data and participant information into
ical aspects of care including psychotropic a secure, encrypted, password-protected data-
medication management when indicated. base using procedures consistent with the
Teachers implemented DBT strategies and Health Insurance Portability and Accountabil-
coaching skill use to address common learning ity Act and The Joint Commission accreditation
processes during educational activities. When requirements.
completing the DBT-A program, participants
reviewed daily goal sheets and reported on skill
use, DBT homework, and diary card comple-
Data Analysis
tion during an opening group. Within problem- Statistical power analysis. We conducted an a
solving groups, problematic behaviors were priori power analysis to identify the number
reviewed, and the group leader supported par- of participants required to establish statistical
ticipants to use behavioral assessment, chain power for our research design at the .80 level
and missing link analyses, and solution analysis. based on a ¼ .05 using the G*Power 3 statisti-
The 7-week DBT skills curriculum is based on cal power analysis program (Faul, Erdfelder,
Rathus and Miller’s (2015) recommendations Lang, & Buchner, 2007). This analysis revealed
Lenz et al. 79

Table 1. Means, Standard Deviations, Reliability Coefficients, and Bivariate Correlations for Scores Among
Scales Used as Predictor and Criterion Variables to Indicate Treatment Gains Over Time.

Variable M SD a 1 2 3 4

1. DERS 1.67 3.48 .90 ** .61 .47 .18

2. INT 4.95 7.42 .91 ** .30 .09
3. FMI 5.57 8.10 .85 ** .24
4. WCCL 10.66 27.31 .94 **
Anxiety 4.53 9.13 .94
Depression 8.85 12.71 .93

Note. DERS ¼ Difficulties in Emotional Regulation Scale; INT ¼ interpersonal sensitivity; FMI ¼ Freiburg Mindfulness
Inventory; WCCL ¼ Ways of Coping Checklist.

that a sample size of 55 was necessary to detect Primary analysis. We modeled relationships
a medium effect between our four predictor between our predictor and criterion variables
variables for estimating change among scores using a simultaneous multiple regression strat-
on the ANX and DEP Scales. Given our sample egy that evaluated the degree that constructs
of 66 participants, we regard our results as associated with emotion regulation, interperso-
defensible for extrapolating relationships nal effectiveness, mindfulness, and distress
between predictor and criterion variables tolerance were predictive of changes in ANX
within our sample. and DEP symptoms among our sample. We
selected this strategy in favor of other regres-
sion approaches based on the assumption that
Preliminary analysis. We used the series mean
although these skills modules are taught
function in the Statistical Package for the
sequentially within DBT-A protocols, they are
Social Sciences, Version 22 (IBM Corporation,
interdependent upon one another for success-
2013), to impute missing values (116 of the
ful mitigation of psychological distress
13,132; 0.008%) within the raw data (see Hau-
(Rathus & Miller, 2015). The four predictor
koos & Newgard, 2007). Values for predictor
variables (DERS, INT, FMI, and WCCL
and criterion variables were computed by cal-
Skills) in this model were regressed indepen-
culating the degree of treatment gain for each
dently onto scores on the ANX and DEP
construct from admission to termination using
Scales. Following, we evaluated percentage
the intended therapeutic change to determine
of explained variance associated with each
directionality. For example, the intent of treat-
model by inspecting R 2 values, regression
ment was to decrease scores on the ANX Scale;
coefficients, p values, and indices estimating
therefore, a participant’s admission score was
practice significance (sr2).
subtracted from their discharge score to yield a
value representing change in ANX symptoms.
This procedure was followed for all constructs Results
to represent how changes in constructs hypothe-
Change Mechanisms for Symptoms
sized as mechanisms of change influence clini-
cal criterion variables. Multicollinearity among
of Anxiety
predictor variables was evaluated by inspecting Means and standard deviations for predictor
bivariate correlations and variance inflation fac- and criterion variables are depicted in Table 1.
tors (see Table 1). Low to moderate intercorrela- The regression analysis estimating the influ-
tions among predictor variables and acceptable ence of predictor variables on ANX Scale
variance inflation factors emerging from our scores yielded a statistically significant model,
analysis suggested that predictive modeling with F(4, 65) ¼ 23.21, p < .01, R2 ¼ .60, indicative
these variables was prudent. of a very large effect size in which model
80 Counseling Outcome Research and Evaluation 7(2)

Table 2. Summary of Regression Models for Emotion Regulation, Interpersonal Sensitivity, Mindfulness, and
Use of DBT Coping Skills as Predictors of Therapeutic Change in Anxiety and Depression Symptoms.

Variable B SE B b t sr2 F R2

Change in anxiety symptoms 23.21 .60

DERS 1.08 .30 .41 3.55* .17
INT .49 .12 .39 3.89* .20
FMI .11 .11 .10 1.02 .02
WCCL-Skills Use < .01 .03 .02 .31 <.01
Change in depression symptoms 29.76 .66
DERS 1.45 .39 .40 3.70* .18
INT .87 .16 .51 5.41* .32
FMI .02 .14 < .01 0.01 <.01
WCCL-Skills Use .03 .03 .07 0.84 .01

Note. DERS ¼ Difficulties in Emotional Regulation Scale; INT ¼ interpersonal sensitivity subscale of the SCL-90R; FMI ¼
Freiburg Mindfulness Scale; WCCL-Skills Use ¼ skill use subscale on the Ways of Coping Checklist; SCL-90R ¼ Symptom
Checklist 90-revised.
*Significant at the .01 level.

predictors account for approximately 60% of Change Mechanisms for Symptoms

the change among scores estimating subjective of Depression
ANX (see Table 2). Within the model, scores
associated with the degree that participants per- The regression analysis estimating the influ-
ceived their abilities to regulate their emotions ence of predictor variables on DEP Scale scores
yielded a strong predictive relationship, yielded a statistically significant model,
b ¼ .41, p < .01, 95% CI [1.69, .47], F(4, 65) ¼ 29.76, p < .01, R2 ¼ .66, indicative
sr2 ¼ .17, indicative of a medium effect size. of a very large effect size in which model pre-
This finding accounted for approximately 17% dictors account for approximately 66% of the
of change among participants’ scores on the change among scores estimating subjective
ANX subscale and can be attributed to the fact DEP (see Table 2). Within the model, scores
that participants who perceived greater gains in associated with the degree that participants per-
their ability to regulate emotions following ceived an ability to regulate their emotions
treatment also tended to report fewer symptoms yielded a robust predictive relationship,
of ANX. Degree of sensitivity to interpersonal b ¼ .40, p < .01, 95% CI [2.23, .66],
interactions was also identified as a statistically sr2 ¼ .18, indicative of a medium effect size.
significant predictor of participant ratings of This finding accounted for approximately 18%
ANX, b ¼ .40, p < .01, 95% CI [.24, .74], of change among participants’ scores on the
sr2 ¼ .20, indicative of a medium effect size. DEP subscale and can be attributed to the fact
This finding accounted for approximately 20% that participants who perceived greater gains in
of change among participants’ scores on the their ability to regulate emotions following
ANX subscale and can be attributed to the fact treatment also tended to report fewer symptoms
that participants who perceived greater gains in of DEP. Degree of sensitivity to interpersonal
their self-consciousness, levels of comfort, and interactions was also identified as a statistically
expectations about interacting with others also significant predictor of participant ratings of
tended to report fewer symptoms of ANX. Non- DEP, b ¼ .51, p < .01, 95% CI [.55, 1.02],
significant findings were detected for scores sr2 ¼ .32, indicative of a large effect size. This
related to mindfulness, b ¼ .10, p ¼ .31, finding accounted for approximately 32% of
95% CI [.33, .10], sr 2 ¼ .02, and use of change among participants’ scores on the DEP
coping skills, b ¼ .03, p ¼ .75, 95% CI subscale and can be attributed to the fact that
[.06, .05], sr2 < .01. participants who perceived greater gains in
Lenz et al. 81

their self-consciousness, levels of comfort, and ANX were at the conclusion of treatment. This
expectations about interacting with others also finding is consistent with Rathus and Miller’s
tended to report fewer symptoms of DEP. Non- (2015) supposition that positive adjustment is a
significant findings were detected for scores function of the ways that individuals accept the
related to mindfulness, b < .01, p ¼ .99, dynamics within relationships while also acting
95% CI [.28, .28], sr2 < .01, and use of coping to improve collaborative communication. We
skills, b < .07, p ¼ .40, 95% CI [.10, .04], also suggest that this finding is supportive of
sr2 ¼ .01. Linehan’s (1993, 2015) biosocial conceptuali-
zation of pathology in which invalidation pro-
motes clinically significant impairments in
Discussion functioning and challenges adaptive function-
Both models indicated that emotion regulation ing. It is possible that interpersonal effective-
and sensitivity to interpersonal interactions ness behaviors learned by our participants
were statistical and practical predictors of during treatment functioned as a second path-
changes within DEP and ANX symptom sever- way to mitigating effects of environments that
ity following DBT-A programming. These our participants perceived as invalidating. Sim-
findings revealed that the more participants ilar to strategies associated with emotional reg-
were able to manage their emotions during ulation, we suggest that with continued mastery
stressful times, the lower their symptoms of of interpersonal effectiveness strategies, ado-
DEP and ANX were at the conclusion of treat- lescents completing DBT-A programming may
ment. These findings are consistent with previ- be better suited to transcend the social com-
ous research by Valentine, Bankoff, Poulin, plexities that characterize adolescence and
Reidler, and Pantalone (2015) regarding the young adulthood in a way that promotes well-
increase of DBT skills acquisition and the being over the life span.
decrease of mental health symptoms related to Interestingly, our analyses did not find
emotion dysregulation. This seems reasonable support for mindfulness and use of DBT
when considering that one arm of the DBT bio- coping skills to tolerate distress as predictors
social model (Linehan, 2015) rests on the pro- of decreased DEP and ANX following DBT-
position that nonadaptive responses are, in part, A programming. We found this finding
a function of the degree that someone is biolo- curious, given that these modules represent
gically vulnerable to experiencing dysregulated core features of DBT and DBT-A protocols.
emotions. Taken together, it is plausible that A number of possibilities might account for
skill acquisition and application learned by our these findings. Our chosen measure of mind-
participants during treatment were able to fulness (FMI) may not be sensitive to dis-
establish a mitigating effect to emotional vul- cerning the skills learned. Additionally, the
nerability. Furthermore, we conjecture that approach to teaching mindfulness skills may
with continued mastery of emotion regulation not provide sufficient understanding of con-
strategies, adolescents completing DBT-A pro- cepts and related activities that promote sub-
gramming may develop skills to manage emo- sequent application and generalization.
tional crises that promote adjustment and Alternatively, skill use as measured the
developmental trajectory into young adulthood. WCCL may be confounded by the wording
Our analyses also detected a strong associa- of the instructions, which asks for assessment
tion between decreases in INT during treatment of skill use during the preceding 4 weeks.
and the likelihood that participants would Reevaluation and amendment of the instruc-
report fewer symptoms of ANX and DEP at tions to make the WCCL more conducive to
discharge. These findings revealed that the our 7-week treatment setting might be indi-
degree which participants were able to be con- cated and create a more accurate depiction
fident and comfortable while interacting with of the degree that these skills contribute to
others, the lower their symptoms of DEP and treatment effect.
82 Counseling Outcome Research and Evaluation 7(2)

It is also possible that these findings may be within the social context that an adolescent
related to the type of social and lifestyle char- completing a partial hospitalization day pro-
acteristics of adolescence rather than the inher- gram may be experiencing. It may not be pos-
ent utility associated with mastering these sible to control for the influence of this external
skills. For example, the typical social context factor within treatment, but attempting to
of a teenager within our sample was one that account for it during treatment planning, family
was characterized by the stigma of mental sessions, and discharge planning may be a help-
health concerns requiring PHP, attempting to ful approach.
maintain relationships with peers at their home When considering the predictive relation-
school, and finding a center of self within the ships between emotion regulation and inter-
treatment process. It is reasonable that the personal effectiveness skills and decreased
convergence of these factors, along with ANX and DEP symptoms, our clinical obser-
ever-present distractions and self-other com- vation has been that the adolescent population
parisons moderated through social media, may appears to learn and apply skills more effec-
have limited mindfulness outcomes measured tively when the learning requires action and
by the FMI (Walach et al., 2006) such as ‘‘I concrete exercises. It is our impression that
feel connected to my experience in the here- action-oriented, hands-on learning activities
and-now’’ and ‘‘I watch my feelings without are easier to implement and more varied in
getting lost in them’’ to a degree that contrib- scope in the emotion regulation and interper-
uted meaningful variance in psychiatric symp- sonal effectiveness modules when compared
toms. Similarly, we suggest that although to some others. For example, skills trainers
learning and using distress tolerance skills are can devise endless role-plays for learning
an important features of DBT-A treatment and interpersonal effectiveness; by contrast, the
recovery, treatment gains associated with this distress tolerance skill of radical acceptance
module may have been superseded by the abil- requires a degree of conceptual development
ity to regulate emotions and be interpersonally and awareness that may be beyond the capac-
effective when distressed. Regardless, these ity of some adolescents, particularly those in
findings merit future research to ascertain the earliest period of adolescence. The activi-
treatment strategies that measure and increase ties for mindfulness and the accepting reality
the treatment effects that mindfulness and dis- component of distress tolerance tend more to
tress tolerance may have within the applica- thinking than doing, and acquisition of these
tions of DBT-A. skills may be more readily realized during the
later adolescent period.
Finally, both interpersonal effectiveness
Implications for Counselors skills and emotion regulation skills may be
In this specific application of DBT-A, the more attuned to pressing developmental tasks
implications for practice and in particular for of adolescence related to identity formation and
skills training are manifold. Counselors will social competence. Interpersonal effectiveness
benefit from maintaining a developmental per- skills are easily linked directly to increasing
spective in the application of skills originally success in navigating peer and family relations,
developed for an adult population. How adoles- while emotion regulation teaches a nomencla-
cents learn, creating concrete opportunities for ture and understanding of emotional life that
learning the more abstract skills and identifying would be of benefit in the critical adolescent
those preferred skills that speak to pressing process of identity formation. These develop-
developmental demands of this age-group, will mental imperatives may make these two skills
all benefit the counselor in providing a strategic more meaningful and pertinent to the adoles-
application of the entire skills package. Consis- cent, and thus, it is worthwhile to consider ways
tent with this perspective, counselors should to highlight these modules as features within a
consider the influence of mental health stigma treatment program.
Lenz et al. 83

Limitations of the Study and relationships between hypothesized mechan-

Recommendations for Future Research isms of change and decreased psychiatric
symptoms among a transdiagnostic sample of
Although this study has provided some insight adolescents. The indication for treatment gains
into the degree that hypothesized mechanisms across emotion regulation and interpersonal
of change within DBT-A are associated with effectiveness domains was present for both
therapeutic change, we concede some impor- ANX and DEP models and contributed a sig-
tant limitations to our study. Foremost, despite nificant amount of variance among scores (60%
our design being adequately powered for statisti- and 66%, respectively). We suggest that
cal analysis, our sample size was modest in nature although these findings are noteworthy, they
(N ¼ 66) and only represented the therapeutic may be limited by a number of factors such
experiences of adolescents within one region of as a sample size and sensitivity of available
the United States. Therefore, interpretations of assessments. Furthermore, it is plausible that
our findings should be approached with caution our findings do not reflect inherent limitations
because they may not be generalized to the of the mindfulness and distress tolerance mod-
broader population of adolescents receiving ules but instead an interaction between content
DBT-A programming. We encourage future and the developmental stage of our partici-
researchers to complete similar analyses and pants. We hope that future researchers will not
encourage replication and extension of our find- only endeavor to replicate our findings but also
ings with larger, more clinically diverse samples. extend the knowledge base depicting the effica-
Additionally, the strength of our inferences cious components of DBT-A through disman-
about mechanisms of change within a DBT-A tling treatments and instrument development.
program was dependent on the current availabil-
ity of related assessments. Currently, the state of Declaration of Conflicting Interests
the art for measuring DBT change mechanisms is
burgeoning but notably limited for nonacademic The author(s) declared no potential conflicts of
practitioners who may be interested in exploring interest with respect to the research, authorship,
constructs such as interpersonal effectiveness, and/or publication of this article.
distress tolerance, mindfulness as depicted within
DBT-A, and activities inherent within the walk- Funding
ing the middle path module. Future scholar- The author(s) received no financial support for
practitioners are encouraged to develop and the research, authorship, and/or publication of
evaluate related assessments that will promote this article.
precision of measurement and accuracy of depict-
ing influences of treatment effect. Finally, the References
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Ritschel, L., Miller, A., & Taylor, V. (2014). Dialec-
tical behavior therapy for emotion dysregulation. Author Biographies
In J. Ehrenreich-May & B. Chu (Eds.), Trans-
A. Stephen Lenz is an assistant professor in the
diagnostic treatments for children and adoles-
Department of Counseling and Educational Psychol-
cents principles and practices (pp. 203–232).
ogy at Texas A&M University-Corpus Christi and a
New York, NY: The Guilford Press. Licensed Professional Counselor. He is coordinator
Salbach-Andrea, H., Bohnekamp, I., Pfeiffer, E., of the Counseling Outcome and Program Evaluation
Lehmkuhl, U., & Miller, A. L. (2008). Dialectical (COPE) research group and his research interests
behavior therapy of anorexia and bulimia nervosa include holistic approaches to counselor develop-
among adolescents: A case series. Cognitive and ment, evidence-supported counseling interventions,
Behavioral Practice, 15, 415–425. community-based program evaluation, and psycho-
Valentine, S. E., Bankoff, S. M., Poulin, R. M., Rei- metric scale development.
dler, E. B., & Pantalone, D. W. (2015). The use of Garry Del Conte, Psy.D. is clinical director at Day-
dialectical behavior therapy skills training as break Treatment Center in Germantown, TN and a
stand-alone treatment: A systematic review of the licensed Psychologist. His clinical specialization is
treatment outcome literature. Journal of Clinical working with children, adolescents, and families in
Psychology, 71, 1–20. doi:10.1002/jclp.22114 partial hospitalization settings.
Verheul, R., van, d. B., Koeter, M. W. J., de Ridder,
K. Michelle Hollenbaugh, PhD, LPC-S, is an assis-
M. A. J., Stijnen, T., & van, d. B. (2003). Dialec-
tant professor in the Department of Counseling and
tical behaviour therapy for women with border- Educational Psychology at Texas A&M University-
line personality disorder: 12-month, randomised Corpus Christi. Her research interests include dialec-
clinical trial in the Netherlands. British Journal tical behavior therapy, assessment, counselor educa-
of Psychiatry, 182, 135–140. tion pedagogy, & evidenced based interventions in
Walach, H., Buchheld, N., Buttenmuller, V., Klein- counseling.
necht, N., & Schmidt, S. (2006). Measuring
Karisse Callendar, MS, LPC, SAC, is a doctoral
mindfulness—The Freiburg Mindfulness Inven-
student in the Department of Counseling and Educa-
tory (FMI). Personality and Individual Differ- tional Psychology at Texas A&M University-Corpus
ences, 40, 1543–1555. doi:10.1016/j.paid.2005. Christi. Her research interests include interventions
11.025 that promote counselor-client working alliance,
Wasser, T., Tyler, R., Mcllhaney, K., Taplin, R., & counseling approaches for individuals with polycys-
Henderson, L. (2008). Effectiveness of tic ovary syndrome, and instrument development.