Family intervention in Dialectical Behavior Therapy (DBT) is a core part of multiple required functions of DBT, providing opportunities for skill training (including relationship-specific skills that are not covered in individual DBT), skill generalization, and direct intervention into the social and family environment. In order to intervene with parents, partners and other family members efficiently and effectively, therapists must first conduct a careful assessment. The core relationship transaction of emotion vulnerability/dysregulation and inaccurate expression leading to invalidating responses (and vice versa) is highlighted, as are the treatment targets in DBT with families, which inform assessment targets. Then, two core assessment procedures are explored, with clinical examples: (a) conducting “double chain” analyses, demonstrating how one person’s social or relationship responses affect the other’s emotional arousal (and vice versa); and (b) direct behavior observation of family interactions, which allow treatment targets to be identified efficiently. These two assessment strategies may also be combined. Implications for family interventions are discussed.
Despite our current zeitgeist of “brain” disorders and “individual psychopathology,” research tells us clearly that individual psychological problems and disorders are multiply-determined, and primarily occur in a relational context, affected in no small way by those relationships (Brown & Harris, 1978; Fruzzetti, 1996). People with borderline personality disorder (BPD) and related problems often struggle in relationships that significantly affect their lives and can either promote or interfere with treatment progress. And, of course, people with BPD and/or severe problems managing their emotion have a big influence on their own relationships and on others.
Consistent with this view, most modern models of developmental psychopathology are transactional, highlighting the bidirectional (or reciprocal) relation between parent behaviors and children’s behavior problems. Similarly, partner involvement, or couple interactions, have been shown to be relevant in the development or exacerbation of many forms of psychopathology (Fruzzetti, 1996; Fruzzetti & Worrall, 2010), and partner involvement and/or couple interventions can aid in the prevention, treatment, or prevention of relapse in a variety of problems (cf. Baucom, Whisman, & Paprocki, 2012). Of course, different models consider different transactional factors, but the focus on mutual influence of factors over time is consistent across models (e.g., Leve & Cicchetti, 2016; Serbin, Kingdon, Ruttle, & Stack, 2015). Indeed, a specific bio-social or transactional model is utilized in Dialectical Behavior Therapy (DBT) to understand the development of borderline personality and related disorders of emotion dysregulation. This framework maintains that BPD specifically and emotion dysregulation in general are the product of (and are maintained by) an emotionally vulnerable individual transacting with, and within, an invalidating social environment (Crowell, Beauchaine, & Linehan, 2009; Fruzzetti, Shenk, & Hoffman, 2005; Fruzzetti & Worrall, 2010; Grove & Crowell, 2017). Of course, in the present model the specific parent behaviors (and other caregivers, and later peer and partner behaviors) are invalidating responses, and the child’s (and later adolescent’s and adult’s) behaviors are inaccurate expression, vulnerability to becoming emotionally dysregulated, and pervasive emotion dysregulation.
DBT affords multiple pathways to help patients not only improve their relationship skills and employ those skills unilaterally (Linehan, 2015; Rathus & Miller, 2014), but also to intervene directly in their close relationships to help improve them via parent, partner, and family skill training (Fruzzetti, 2006; Fruzzetti, in press; Hoffman, Fruzzetti, & Swenson, 1999) or DBT family therapy (Fruzzetti, 2018; Fruzzetti & Payne, 2015; Fruzzetti, Payne, and Hoffman, in press). Thus, there may be a variety of reasons why a DBT therapist may want to assess directly (and likely intervene with) the client’s family and client-family member transactions.