There were numerous challenges to treatment. Most notably, the family missed, Akt inhibitor was late to, or cancelled at the last minute numerous individual, group, and WBC sessions.

This was most often due to Lance’s refusal to come to therapy but also due to parental tardiness or family/personal crises not related to SR. Further, Lance often became unresponsive when the therapist tried to address school topics directly discussed. The family’s inconsistency and Lance’s avoidance of emotional topics led to a large proportion of session time dedicated to treatment engagement exercises and motivational interviewing. The parents’ own avoidance of the topic (as discussed above) only reinforced the youth’s avoidance and gave little incentive to participate actively in session. In the sixth week of the program, Lance began psychopharmacological treatment with an SSRI, and he reentered school in the 12th week. After school reentry, the family’s treatment

attendance decreased and commitment became unstable. Decreased attendance may have resulted from continued Fulvestrant order treatment disengagement, recovery from distress via DBT-SR or the medication, or logistical challenges with balancing travel to school, homework, and travel to the treatment facility. It should be noted that Lance’s mother and father both acknowledged gaining personal benefit from participating in the skills group. Lance and his mother’s emotion dysregulation were intertwined in a number of ways. For example, the mother had difficulty tolerating Lance’s distress and would become upset when Lance was distressed. When upset, the mother resorted to coercive tactics to elicit Lance’s compliance with desired behaviors (e.g., screaming and threatening when it was time to go to therapy). Practicing skills with the mother helped her

keep her emotions regulated and adhere to family interventions calmly (e.g., contingency management; avoid switching between “Too loose” and “Too strict”). The father presented with greater emotion regulation, but he self-acknowledged having an avoidant coping style. This often meant the father avoided pheromone communicating with the therapist or telling the therapist at the last-minute when he had done something against recommendations (e.g., cancelling WBC at midnight by text because he had made a deal with Lance that he did not have to get up for coaching). As a result, the father would agree with therapist recommendations in session, but then fail to consistently implement strategies at home. Lance’s treatment relied heavily on WBC and phone coaching. WBC was scheduled nearly daily until Lance reentered school. Having coaching take place via videoconferencing was particularly helpful because the therapist could see and speak to multiple family members in order to assess interactions between family members. Videoconferencing was also helpful because the therapist could see Lance’s body language when he was not verbally responsive.