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Does DBT Work for Teen Depression?

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT
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Chances are, you’ve heard of Dialectical Behavior Therapy (DBT). In the world of teen mental health treatment, DBT has been gaining more and more popularity over the years. Whether you first learned about it from a friend, family member, your child’s school counselor or therapist, or even Selena Gomez, there’s a reason why therapists are embracing this evidence-based treatment modality and are receiving specialty certifications to practice DBT: It works!

But if you’ve done any research in efforts to find help for your depressed adolescent, you might have read that Dialectical Behavior Therapy was first developed to treat borderline personality disorder. So…does it actually work for depression? And if so, how?

Marsha Linehan and DBT

Dr. Marsha Linehan came up with Dialectical Behavior Therapy in the 1980s while working with her borderline personality disorder patients. She was treating them with cognitive behavioral therapy (CBT) but found that many of them weren’t getting better. These patients self-harmed, frequently attempted suicide, and had extreme, intense emotions.

That’s when she developed DBT, and found a lot of success. Dialectical Behavior Therapy worked when nothing else did.

After recognizing the efficacy of Dialectical Behavior Therapy for borderline symptoms, practitioners began analyzing whether the therapy worked to treat other mental health illnesses, such as depression, anxiety, or Posttraumatic Stress Disorder. A myriad of studies proved that it did, primarily because these illnesses had common symptomology with those of borderline patients: extreme emotion dysregulation, frequent self-harming, and chronic suicidal attempts.

What is DBT?

Let’s go backward for a minute: What is DBT, anyway?

DBT is a structured, skills-based therapy that helps people live “a life worth living.” A trained DBT therapist teaches patients certain skills they need to accomplish their goals and reduce behaviors that get in the way of achieving these goals.

There are five modules of Dialectical Behavior Therapy skills, which also correspond to five areas that depressed teens struggle with:

  1. Navigating up-and-down emotions (in DBT, this is called emotion regulation)
  2. Managing relationships appropriately (interpersonal effectiveness)
  3. Tolerating difficult emotions safely and reducing suffering through reality acceptance (distress tolerance)
  4. Increasing one’s awareness and focus in the present moment (core mindfulness)
  5. Finding balance between two extremes (walking the middle path)

These skills are the core pillars of DBT, and they are utilized during a teen’s individual sessions with his/her therapist, group sessions with milieu peers, and one-on-one skills coaching when crises arise. (For a more in-depth explanation of Dialectical Behavior Therapy, check out our DBT Parent Guide.)

How Will Dialectical Behavior Therapy Treat Depression?

Teens with depression may exhibit the following symptoms:

  • Frequent, all-consuming sadness
  • Moodiness
  • Isolation from family and friends
  • Feeling worthless
  • Feeling hopeless about the future
  • Irritability
  • Angry outbursts
  • Loss of interest in activities you once found pleasurable
  • Low frustration tolerance
  • Excessive guilt or self-blame
  • Self-harming behaviors*
  • Suicidal thoughts/attempts*

* If you or someone you love is having thoughts of suicide or self-harm, never ignore it. Call  1-800-273-8255 immediately or go to the nearest emergency room.

Let’s get into some primary depression symptoms in more depth, and see how specific DBT skills may be applied:

1. Always sad:

More than just having a bad day, depression is pervasive—your teen can’t shake it off. They’re stuck. Depression also causes moodiness, irritability, and bouts of anger. Teens usually lose interest in friends, family, hobbies, and activities they once liked.

DBT skills teach them how to recognize and identify their sadness and actively try to substitute sadness with more positive emotions.

For example, Mindfulness skills teach teens to be nonjudgmental of their emotions, and not beat themselves up when they find themselves feeling sad, lonely, or negative. Every day during your teen’s DBT treatment, your child will track and rate their sadness on a scale of 1-10 or 1-100 through Daily Diary Cards.

Teens learn to observe and describe their own depressed thoughts as this is what is. That these thoughts are neither good or bad…they just are. By thinking nonjudgmentally like this, your teen will start being able to accept their feelings as valid. Once teens radically accept reality (whatever their reality looks like at any given moment), the battle is already half-won. Precious energy can now be spent towards improving reality for the better. Mindfulness also teaches patients to go with the flow, or “ride the surf” of the emotion. Believe it or not, just this tool alone helps decrease sad feelings.

  • Behavioral Activation

Another key component of treating depression through DBT is behavioral activation. This method encourages teens to engage in activities that are likely to produce positive emotions as a way of reducing the sadness associated with depression. For example, the DBT skill of “Opposite Action” in the Emotion Regulation module works through behavioral activation. Opposite Action encourages your teen to do the exact opposite of what they want to do when they’re depressed. So, for instance, if your teen wants to stay in bed all day with the blinds drawn, Opposite Action tells them to get up, go out, approach others, and/or push themselves to take part in pleasant activities that they used to enjoy—whether it’s cooking, art, sports, reading, or something else—despite the fact that your depressed teen may feel they cannot, or don’t deserve, to feel more positive.

2. Urges of self-harm and suicide:

When your child is depressed, it’s hard to deal with the pain. Some teens hurt themselves as a way of escaping this pain. Problem is, pain is a part of life, and we need to find better ways to deal with it.

DBT’s Distress Tolerance skills will teach your child ways to safely and quickly deal with their pain instead of acting on their urges. Skills like “Wise Mind A.C.C.E.P.T.S,” “Self-Soothe,” “I.M.P.R.O.V.E. the Moment,” “Pros and Cons,” and “T.I.P.P.” are last-resort options to survive a crisis when you don’t want to make the situation worse. When you study DBT, or during your child’s family therapy sessions, you’ll know exactly what these mnemonics stand for!

These skills also come in handy when your child is hurt by others in their environment. If your child is rejected by a classmate, or experiences a major disappointment, these distress tolerance skills help them learn how to properly respond instead of internalizing the interaction, which can cause your teen to spiral downwards into a pit of self-doubt, withdrawal, anxiety, and self-harming actions.

  • Behavior Chain Analysis

    If your child cannot control their urges and somehow engages in a problematic or therapy-interfering behavior, the therapist may ask them to fill out a Behavior Chain Analysis in their Dialectical Behavior Therapy Workbook. This tool asks the patient to reflect on every single step, including the vulnerabilities, feelings, and thoughts the patient was experiencing just prior to the behavior, that led to the problem behavior (i.e. the self-harm episode, suicide attempt, etc.). After writing this all down, the therapist and teen look back at the chain of factors that contributed to the problematic behavior. They then determine at which moment things could have been done differently to prevent the end result from occurring.

    The Chain Analysis is a major DBT tool that teaches depressed teens how to identify all the factors, or “links,” that place them at risk for a problem behavior, and how to “break the chain” in the future by taking early-intervention measures.

3. Feeling worthless, always harsh on yourself:

Teens with depression usually feel worthless, meaningless, and like their future holds no hope. When they experience disappointment or a setback, they blame themselves, even if they had no part to play. DBT teaches your teen to take a broad view of the situation, “Check the Facts,” and employ Opposite Action when their shame/guilt doesn’t fit the facts.

Dialectical Behavior Therapy also teaches your teen how to prevent depressive thoughts from surfacing in the first place. Utilizing the “ABC PLEASE” skill in the Emotion Regulation Module, teens learn how to increase their feelings of positivity by participating in pleasant activities as many times in the week as possible and building mastery in specific tasks they are talented at. Teens are encouraged, on a regular basis, to visualize potential scenarios they will face in the future that trigger their depressed thoughts (such as being ignored at school, not being asked out, or receiving a low grade on an assignment) and how they can cope ahead of time with the situation to prevent their depression (and subsequent behaviors, such as urges to self-harm) from surfacing. This skill, like Opposite Action, also works through behavioral activation.

Lastly, DBT strongly emphasizes the correlation between lack of self-care and depression (and the opposite: proper self-care and positivity). “PLEASE” teaches teens to engage in daily exercise, eat healthy, balanced meals, get the proper amount of sleep per night, stay off alcohol and street drugs, and see a doctor whenever necessary.

This is just a brief sneak peek of how DBT can help with depression.

DBT Effectiveness Studies

Dialectical Behavior Therapy is evidence-based: scientific studies have proven it works. Here are just a few articles showing how Dialectical Behavior Therapy successfully treats depressive symptoms:

  • Seventy-five percent of depressed adults treated with Dialectical Behavior Therapy and medication reported remission after a year. In the medication-only group, only 31% did the same (Lynch, 2003).
  • Oppositional adolescents given DBT skills-training saw a decrease in their depression symptoms, and their caregivers reported an increase in positive behavior, too (Nelson-Gray, ‎2006).
  • Depressed participants who took part in DBT skills-training for 16 sessions saw a significant decrease in their depressive symptoms than the control group (Harley, 2008).
  • Out of a group of 77 self-injurious teens, those treated with DBT had lower levels of depression, self-harm, and suicidal ideation than the teens who received usual care(Mehlum, 2014)
  • After 19 weeks, and a year of follow up, adolescents who had received DBT on the outpatient level self-harmed less frequently than those in the control group, who received standard care. The teens in the DBT group also recovered from their depression more quickly than those in the control group (Mehlum, 2016).
  • Over a period of six months, 173 highly suicidal adolescents received either DBT or standard individual and group therapy. After treatment, a higher percentage of teens in the DBT group refrained from suicide attempts and self-harming behavior than in the control (McCauley, 2018).

As you can see, Dialectical Behavior Therapy is a proven treatment modality that has been effective for almost forty years. Willing to let your child give it a try?

Where to Get DBT Treatment for Your Depressed Teen

Because DBT is a skills-based therapy, your child will need to learn these skills from a DBT-trained therapist. Along with skills-groups, a core part of DBT is having the option to speak with one’s therapist between sessions when necessary. The DBT therapist will help your adolescent apply the skills during a crisis.

Individual therapists usually run adolescent DBT-skills groups in their outpatient practice, coupled with weekly individual sessions and coaching, over the course of a year.  If your child’s depression is more severe, an immersive program may be indicated for stabilization.

Our teen treatment centers offer options at three levels of care. Depending on the severity of your teen’s depression, your child can receive care at a Residential (RTC), Partial Hospitalization (PHP) or Intensive Outpatient (IOP) program.

Residential Treatment

If your child needs full-time depression treatment, they’ll stay in a non-hospital treatment facility that specializes in treating adolescents with depression. Your child will be immersed in DBT with teens going through similar issues. Teens participate in skills groups with their milieu peers and receive in-the-moment client coaching, 24/7, whenever they need it. Every encounter can be a potential DBT-skills lesson—at breakfast, an outing, or bedtime—and counselors will direct the teens to apply DBT skills when appropriate. Residential treatment often lasts between 30 to 60 days, depending on the disorder and its severity.

Partial Hospitalization Program

In a Partial Hospitalization Program (PHP), teens attend programming at least five hours per day, five days a week. At this level of care, teens receive a full day of treatment but continue to live at home. Partial hospitalization is an effective alternative to residential or inpatient treatment when depressive symptoms do not require 24/7 monitoring. It may be appropriate for those transitioning from an RTC or those who need more structure than an IOP.

Intensive Outpatient Program

An Intensive Outpatient Program (IOP) for depression is a less intensive option than PHP. At the intensive outpatient level of care, teens receive a half day of professional treatment. Most teens in IOP are able to attend school and live at home. Intensive outpatient is an effective alternative to residential or partial hospitalization programs. It may be appropriate for teenagers who need more structure than private practice psychotherapy for their depression. The number of hours in an Intensive Outpatient Program may vary, but generally, teens in IOP receive 3-4 hours of treatment up to four days a week.

Whether it’s a DBT therapist or teen rehab center; residential treatment, IOP or PHP, get in touch with a Dialectical Behavior Therapy program for teen depression today. Let your child start building, as they say in the DBT world, a life worth living.

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