There is always a potential risk for alliance ruptures or alienating one or more members of the family when multiple family members are involved, particularly when the primary

reason for referral is youth school attendance. Group leaders in the skills group were careful to iterate repeatedly that DBT skills were useful for all and reinforced this notion by pushing each attendee, parents and youth, to disclose examples to connect the material to their personal lives. Experientially, this approach worked to engage the parents in the group and many disclosed the personal relevance of the skills. However, the youth appeared to be less engaged in the group over time (there were twice as many adults in the room as youth), and one member dropped out after one group meeting because she preferred youth-only groups. Original multi-family Z-VAD-FMK CDK inhibition groups of DBT (Miller et al., 2007) included parents and youth in the same group, but future trials of DBT-SR might experiment with having youth-only and parent-only groups. In individual and WBC sessions, therapists felt they heavily relied on coaching parents to administer DBT interventions with the youth. Many WBC sessions

were used to coach parents as the youth refused to come to the computer. The therapist for Lance felt that this alienated the client and challenged their working alliance. This dynamic was particularly exacerbated by the need to strengthen both parents’ skills in coaching sessions. SPTLC1 There were multiple instances where Lance re-directed the therapist’s coaching efforts toward the mother, as he believed she needed the most help. The therapist for Ricky felt they were

able to balance the structure better, because the youth accepted the need for help more. Future versions of DBT-SR might incorporate techniques from interventions focused on oppositional behavior and parent-youth interactions (e.g., Parent Child Interaction Therapy, Parent Management Therapy) to better accommodate these dynamics. What to Do about Attendance Rules? Traditional DBT applies strict attendance rules for continued participation in the skills group and individual therapy (“the four miss rule” in standard DBT which states that a client is out of DBT if they miss four individual or group sessions in a row; DBT-A states that a participant can miss up to four individual sessions or groups within the 16-week treatment before they are terminated from treatment). Parent attendance at skills groups and individual sessions was adequate, if not perfect, but youth attendance at skills groups was poor and intermittent in individual/WBC sessions. In considering whether we should apply a hard rule for attendance consistent with the DBT model, we were forced to account for the nature of the problem we were treating.