Demystifying DBT with Adolescents

by Natalie Zervas, PhD

Demystifying DBTOne of the benefits of working in the mental health field today is that the availability of evidence-based treatments has greatly increased in recent years. However, this increase can be a double-edged sword. With this greater variety of effective treatments comes the need for increased training on the part of providers and increased understanding of the treatments by consumers. This understanding can be particularly difficult to achieve in the treatment of less studied mental health problems faced by our children and adolescents. Non-suicidal self-injury (NSSI) and suicidality are examples of such problems. Seen with growing frequency by schools, families, pediatricians, and mental health care providers, detailed information about effective treatments for these presenting problems has not been adequately disseminated to either the professional community treating these youth or the families who love and care for them. 

Dialectical Behavior Therapy (DBT) is a treatment with growing empirical support that has been found to be effective in treating NSSI and suicidality, as well other problematic impulsive behaviors in adults, with promising research support in adolescents as well (Groves et al., 2012; Mehlum et al., 2014). Unfortunately, solid understanding of its treatment rationale and structure remains lacking among mental health professionals. Without the understanding of what comprises effective DBT, providers and families are ill served as they seek appropriate services. To address the current need among youth and families, this article provides a practical overview of the fundamentals and treatment components of effective DBT for adolescents (DBT-A).

December 2014 Vol. 30, No. 12CABL logoThis article was published in the Brown University Child and Adolescent Behavior Letter in cooperation with Bradley Hospital.

DBT Background

Dialectical Behavior Therapy (DBT) is an empirically-supported treatment developed by Marsha Linehan, PhD, ABPP, over 20 years ago (Linehan, 1993a, 1993b). It grew out of a need for an effective treatment to help a difficult to treat population for whom standard cognitive behavioral therapy (CBT) and supportive therapies were not beneficial. DBT is a modification of standard CBT that balances the change focus of CBT (i.e., the need to stop engaging in NSSI) with the acceptance strategies of other types of therapy (i.e., validating that NSSI works for you temporarily). The balance between these acceptance and change strategies in DBT forms the fundamental “dialectic” that resulted in the treatment’s name. In brief, dialectic is the existence or action of opposing ideas or concepts. 

Originally developed to treat chronically suicidal adults also suffering from borderline personality disorder (BPD), DBT has since been found to be especially effective for individuals with suicidality, NSSI, and other dysfunctional behaviors (e.g., eating disorders, substance abuse), with the core problem being extreme emotion dysregulation. With these individuals, research has shown DBT to be effective in reducing suicidal behavior, psychiatric hospitalization, treatment dropout, substance abuse, anger, and interpersonal difficulties (Linehan, et. al., 1999). After identifying a need for an effective treatment for suicidal and self-injurious adolescents, Alec Miller, Psy.D. and Jill Rathus, PhD, along with Marsha Linehan, successfully adapted the treatment for use with adolescents (Miller, Rathus, & Linehan, 2007). Notably, DBT has been successfully implemented across a variety of ethnic and socio-economic backgrounds (Rathus & Miller, 2002), with research on the efficacy of DBT-A being ongoing.

DBT Treatment Overview

Below are some key points for providers and families to know about DBT as they consider the appropriateness of the treatment. Please note that the information provided below is based on an outpatient DBT-A program Other types of DBT-A treatment are available (e.g., inpatient, residential, etc.) and may have different structures of treatment. For a thorough overview of DBT-A pleaser refer to Miller, Rathus, and Linehan (2007). 

What problems does DBT-A treat? 

DBT-A addresses five major problem areas through a variety of treatment modes and specific skills (addressed below). These five areas include:

  1. Confusion about Self (identity confusion, unawareness of emotions, dissociation, emptiness)
  2. Emotion Dysregulation (emotional liability, angry outbursts)
  3. Impulsivity (NSSI, substance abuse, aggression, suicidal threats/actions)
  4. Interpersonal Problems (unstable relationships, interpersonal conflict, social isolation, loss)
  5. Parent-Teen Dilemmas (poor problem solving, rigid thinking, poor communication)

DBT-A addresses problems in a structured way.

When an adolescent is in individual DBT-A, their life-threatening behaviors are addressed first, often utilizing behavior chain analysis as a way to better understand the problematic behavior (e.g., NSSI, suicidal ideation). From there, behaviors that negatively impact therapy (e.g., lateness, missed sessions, limited engagement in sessions) are addressed, followed by behaviors that negatively impact the adolescent’s quality of life (e.g., depressed mood, conflict with peers, anxiety).

DBT-A is a multi-modal treatment. 

When DBT-A is provided in a comprehensive, evidence-based way, it includes three main modes of treatment:

  1. Individual (and Family) Therapy
    • Sessions occur 1 to 2 times per week for 45 to 50 minutes with the adolescent’s individual therapist.
    • This modality exists to help adolescents build motivation to work toward change and apply the skills they learn during group sessions to their daily experiences.
  2. Multi-Family Skills Group
    • Sessions occur weekly for 2 hours. They include parents and other adolescents/parents and are run by two leaders.
    • This modality exists to teach adolescents and parents new skills to help them move closer to achieving their treatment and life goals.
  3. Phone Consultation
    • This modality exists to promote skills generalization by helping adolescents implement skills in real-life situations and in real-time. Adolescents are encouraged to call their individual therapist for skills coaching when they are “in crisis” (e.g., urges arise to engage in maladaptive behaviors) prior to engaging in a problematic behavior (e.g., NSSI). Similarly, parents are encouraged to call their assigned skills group leader when they are in need of coaching to use skills learned in group (e.g., during a conflict with adolescent).

DBT-A is a team treatment.

An additional component of DBT-A exists to help ensure therapists are providing the best possible care for adolescents and families. This is called consultation team and is a weekly meeting attended by all DBT therapists on a team during which guidance and support is provided to all therapists by all therapists.

DBT-A utilizes a diary card.

An essential component of individual DBT-A is an adolescent’s completion of a diary card. This tool is a way for adolescents to self-monitor their behavioral urges and actions, as well as their emotions week to week. The diary card is then shared during individual sessions, providing a snap shot of the week. Notably, it is something meant to be shared between an adolescent and their provider only, and not shared with parents (within the general limits of confidentiality and safety).

DBT is a principle-based treatment, rather than a manualized treatment.

This means that it follows general principles throughout its course with flexibility to address relevant topics within its structure. It is important to note that, should an adolescent enter into DBT-A, the best resource of information regarding the specific structure of their treatment will be their provider. More specific information would be provided to the adolescent and family on each of these topics once the treatment began.

Treatment Options

Finding thoroughly trained DBT-A providers can be difficult. Locating comprehensive DBT treatment in your area can be even more challenging. At present, there are several online resources for locating quality treatment providers in your area. The following websites provide access to providers specializing in DBT (in addition to other treatments):

In deciding on appropriate treatment for an adolescent, consultation with and among professionals is invaluable. To provide some additional and specified guidance, included below are some questions to consider when contemplating whether an adolescent might benefit from DBT-A.

  • Are they chronically suicidal and/or engaging in NSSI?
  • Are they chronically emotionally dysregulated?
  • Are they engaging in repeated problematic, self-destructive impulsive behaviors?
  • Do they have difficulty making or keeping interpersonal relationships?
  • Have they had difficulty remaining in other standard types of therapy?

Additionally, here are some questions to keep in mind when choosing a provider and/or treatment program:

  • Are they licensed to provide mental health treatment?
  • What type of degree do they have?
  • What is their DBT training (were they intensively trained and by whom)?
  • Do they practice as part of a DBT consultation team?
  • What components of DBT do they offer (individual, group, phone coaching)?

Choosing effective mental health treatment for adolescents remains a challenging and often confusing task. No formula exists for who might benefit from a particular type of therapy and many factors go into what makes a treatment ultimately effective. While this complexity is likely to persist, the importance of disseminating accessible information about what constitutes evidence-based DBT-A and for whom this treatment could be effective cannot be overstated. Hopefully, an increased understanding by practitioners and consumers will come along with this improved communication, and adolescents and families struggling with the problems addressed by DBT-A will begin to receive more effective and appropriate treatment.


Natalie Zervas, PhD, is a staff psychologist in outpatient and crisis services at Bradley Hospital specializing in the treatment of non-suicidal self-injury and suicidality in adolescents. She is also a clinical assistant professor in the department of psychiatry and human behavior at the Alpert Medical School of Brown University.


References

Groves S, Backer HS, van den Bosch W, Miller A. Dialectical behavior therapy with adolescents. Child Adolesc Ment Health 2012; 17(2):65–75.

Linehan MM. Cognitive behavioral therapy for borderline personality disorder. New York, NY: Guilford Press; 1993a.

Linehan MM. Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press; 1993b.

Linehan MM, Schmidt H, Dimeff LA, Kanter JW, Craft JC, Comtois KA, Recknor KL. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. Am J Addict 1999; 8(4):279–292.

Mehlum L., et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: A randomized trial. J Am Acad Child Adolesc Psychiatry 2014; 53(10):1082–1091.

Miller AL, Rathus JH, Linehan MM. Dialectical behavior therapy for suicidal adolescents. New York, NY: Guilford Press; 2007.

Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav 2002; 32:146–157.