Dialectical Behavior Therapy (DBT) is gaining more and more exposure as parents and therapists are recognizing its remarkable value in helping teens with emotional dysregulation, self-harming behavior, suicidal ideation, and other mental health and/or behavioral issues. If your child’s counselor or clinician recommended DBT treatment, know that providing this therapy to your teen can be a life-changing gift for both of you. Read on to find out what DBT is, how it can help your adolescent, and different ways it can be administered.
What is DBT?
DBT is a structured, skills-based therapy that helps people live “a life worth living.” This means 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 for adolescents:
- Navigating up-and-down emotions (in DBT, this is called emotion regulation)
- Managing relationships appropriately (interpersonal effectiveness)
- Tolerating difficult emotions safely and reduce suffering through reality acceptance (distress tolerance)
- Increasing one’s awareness and focus in the present moment (core mindfulness)
- Finding balance between two extremes (walking the middle path)
These skills are the core pillars of Dialectical Behavior Therapy, and they are utilized during your teen’s individual sessions with his/her therapist, group sessions with milieu peers, and one-on-one coaching during crises.
Difference Between CBT and DBT
Now, you may have heard of Cognitive Behavioral Therapy (CBT)… but DBT? What’s the difference?
One of our therapists has an easy way of explaining it: CBT is “inside-out” therapy, while DBT is “outside-in.”
What do we mean by that?
With CBT, you work with a therapist to primarily change your thinking patterns, so that your emotions and behavior change as a result. In DBT, you work to change emotions and behavior, by learning practical, actionable skills you can do today, and then your ineffective thinking changes as a result. DBT also places more emphasis on accepting your life, the way it is now, while working to improve it. In other words, CBT is based on the idea that your thoughts impact how you feel and what you do. DBT is based on the idea that persistent difficulty regulating emotion influences all aspects of one’s behavior.
History of DBT
Dr. Marsha Linehan developed Dialectical Behavior Therapy in the late 1980s as an adaptation of Cognitive Behavioral Therapy. While treating her borderline personality patients with CBT, she found that many of them weren’t getting better. These patients self-harmed, frequently attempted suicide, and had extreme emotions.
Linehan realized these patients needed a heavy dose of self-acceptance first (this later turned into her “radical acceptance” theory) before they even began trying to change their behavior. Ironic as it sounds, she saw that people are more willing to change if they are first immersed in an atmosphere of affirmation.
We think she explained it best when she wrote the following:
“In a nutshell, DBT is very simple. The therapist creates a context of validating rather than blaming the patient, and within that context the therapist blocks or extinguishes bad behaviors, drags good behaviors out of the patient, and figures out a way to make the good behaviors so reinforcing that the patient continues the good ones and stops the bad ones.”
(Linehan, Cognitive Behavioral Treatment of Borderline Personality Disorder)
DBT: What Does Dialectical Mean?
DBT as a whole discourages all-or-nothing thinking patterns. Instead, it encourages finding the middle path between two extremes. Fun fact: this philosophy was inspired by Zen practices, which Linehan was studying when she created DBT.
The dialectical perspective is specifically beneficial for teenagers, whose extreme, all-or-nothing thinking often influences their behavior. It is for this reason that Adolescent DBT has an added fifth skill of Walking the Middle Path, a skill that’s excluded from standard DBT for adults. The skills learned in this category help adolescents balance extreme thinking patterns, behaviors, and approaches to life.
Applying a Dialectical Approach
For example—if your anxious daughter frequently says, I do everything wrong. I can’t get anything right, DBT would encourage her to replace that with I am proud of myself, and I must still try to improve. Note: DBT discourages the use of the conjunction “but”!
Instead of thinking I’m all good or I’m all bad, Dialectical Behavior Therapy encourages replacing those two extremes with Sometimes I do things that aren’t effective, and other times I do things that are. This helps increase your child’s self-acceptance, ultimately serving as a way to change their behavior.
This dialectical way of thinking also applies in cases of relapse. If your adolescent son, who struggles with alcohol, breaks his or her period of sobriety with a drink at a party, he may immediately think he’s “a terrible person.” Overwhelmed by waves of guilt, and failing to place this one drink in the context of his overall progress, he may subsequently begin binge-drinking and engaging in a self-destructive drinking spree.
This is an illustration of DBT’s key philosophy: to step out of an extreme all-or-nothing approach and instead take a dialectical perspective. It’s all about accepting yourself – including all the ways you’re fallible! – while still telling yourself you can change. Radical acceptance, and acknowledgment to improve. Validating yourself, and solving the problems in your life.
Why is DBT So Effective for Adolescents?
While Dr. Linehan was seeing success using Dialectical Behavior Therapy with her patients diagnosed with borderline personality disorder, other practitioners decided to start using (or adapting) this evidence-based treatment modality to other populations: patients with depression, anxiety, posttraumatic stress disorder, substance abuse, eating disorders, and other mental health issues.
Dialectical Behavior Therapy was effective for all these illnesses, and studies showed how patients with high emotional sensitivity and high reactivity, especially teens who frequently self-harmed and attempted suicide, responded better to DBT than they had to other therapies. In many instances, Dialectical Behavior Therapy was the only therapy that worked.
According to Behavioral Tech, Dr. Marsha Linehan’s DBT training institute, Dialectical Behavior Therapy helps:
- Suicidal and self-harming adolescents
- Pre-adolescent children with severe emotional and behavioral dysregulation
- Major depression
- Posttraumatic stress disorder related to childhood sexual abuse
- Borderline personality disorder/symptoms
- Narcissistic/antisocial/histrionic personality disorders
- Attention deficit hyperactivity disorder (ADHD)
- Bipolar disorder
- Trans-diagnostic emotion dysregulation
- Binge eating disorder
- Bulimia nervosa
While DBT can help anyone, it is especially helpful for adolescents. Puberty brings with it dramatic changes in your child’s brain, especially in the prefrontal cortex, the decision-making part of the brain that controls impulses and considers the consequences of actions. As the prefrontal cortex is still under construction, teenagers may be more impulsive, emotional, reckless, and/or aggressive from the age of 12 through young adulthood.
As teens biologically have difficulty controlling their impulses during the adolescence stage, imagine how much harder it is for those teens who have pre-existing emotion dysregulation from a mental-health disorder.
If your child has been referred for Dialectical Behavior Therapy due to his or her emotion dysregulation, you may have noticed his or her high sensitivity and reactivity even from a young age. The environment around them, such as the family or school system, may have reinforced or punished these emotional reactions, which may then have caused your teen to turn to substances (like alcohol or drugs) or problematic behaviors (such as self-injurious behaviors or even suicide attempts) to try to cope. Now, these behaviors or substances have become the go-to coping mechanisms, even when commonplace emotions come up.
DBT treatment is beneficial here because it attempts to accomplish several things:
- Eliminate ineffective problem behaviors, +
- Teach adolescents skills for coping with their emotions safely (e.g. without hurting themselves and without resorting to harmful substances)
… So that your teen can reach the all-around goal of DBT = to live a life worth living.
DBT as an Evidence-Based Practice
Other things you should know about DBT:
This treatment is based on heavy research, so you can rest assured that your teen is being given skills that are proven to work. Every aspect of DBT is formulaic and altered over time based on the latest research developments. DBT’s efficacy and effectiveness have been studied in both academic and community settings since the 1980s.
It’s based on the biosocial theory.
Dialectical Behavior Therapy is based on the theory that emotional dysregulation is a result of both nature and nurture. Your teenager’s high emotional sensitivities may be innate, but his/her behavior problems may be a result of these biological vulnerabilities interacting with an invalidating environment (which can include family, teachers, friends, and others).
It operates under certain assumptions.
All DBT therapists approach their teenage patients assuming that teens are doing the best they can, that they have a sincere desire to improve, and that they cannot fail in Dialectical Behavior Therapy. These assumptions influence how your therapist approaches your adolescent’s case.
There are four stages.
The DBT House of Treatment model, created by Dr. Marsha Linehan, explains these four levels of Dialectical Behavior Therapy. As your teen’s behaviors and goals change over time, he or she can move through all these stages of treatment, starting from the “basement” and finally climbing up to the “roof.”
There are four components of treatment delivery.
In a comprehensive DBT program, the teen rehab center must offer all four aspects of DBT: individual/family therapy, skills-training groups, skills coaching, and therapists’ consultation team. A program that offers one to three of these components is a DBT-informed program. Learn more about the difference between comprehensive DBT and DBT-informed teen rehab centers.
Intensive DBT Teen Rehabilitation Options
So, you think you’re ready for your teen to start Dialectical Behavior Therapy. Now, where do you go? The severity of your adolescent’s illness will dictate which level of care you need. Teens can receive Dialectical Behavior Therapy at any level of care.
Teens who choose an outpatient (OP) level of care can safely manage to live at home and attend school. Standard outpatient DBT is typically a one-year commitment. Teens learn the entire DBT skills-modules curriculum over a span of six months. Then, the same material is repeated a second time around over the next six months, allowing teens to internalize the DBT concepts and skills in more depth. The standard outpatient model provides one DBT skills class a week and one individual/family therapy session a week, in addition to between-sessions phone coaching as needed.
Your child may be appropriate for an Intensive Outpatient DBT program (IOP) if he or she is able to safely live at home and attend school, as IOP typically provides a half-day of professional treatment three to four times a week. Dialectical Behavior Therapy is provided at a more accelerated pace than in standard outpatient. Teens have a skills-training group every day and an individual therapy session once a week, and oftentimes a family therapy session weekly as well.
PHP is a more intense level of outpatient care than IOP. If your teen is still engaging in target behaviors but does not require round-the-clock supervision, he or she may require a partial hospitalization program (PHP). Teens in PHP usually live at home but may not be able to attend school. As in IOP, Dialectical Behavior Therapy is provided at a more accelerated pace than in standard outpatient. Teens have a skills-training group every day and an individual therapy session once a week, and oftentimes a family therapy session weekly as well.
If your child is in crisis, and can barely cope with day-to-day life, they need to attend a residential treatment center (RTC), where they will receive 24/7 supervised care and live full-time at a facility. While residential treatment primarily focuses on eliminating all life-threatening behaviors, treatment-interfering behaviors, and behaviors that severely impact functioning, one can receive Dialectical Behavior Therapy on this level of care, as well.
Residential Treatment Centers condense the DBT skills modules into an immersive, high-impact curriculum that exposes teens to the skills well into their stabilization phase (even though teens in inpatient treatment may not be ready to start implementing the skills in daily life as of yet). This provides a jumpstart to teens’ recovery, as they are starting to use the skills relatively immediately after a crisis hits. They will benefit from gaining a grasp of the skills language and thinking patterns even before they are able to apply them in day-to-day, outside-world situations (which they will eventually do in outpatient care).
Post-treatment plans can vary entirely from one client to another. For example, if your teen has successfully discharged from a DBT residential treatment center (RTC), their aftercare plan may indicate a Partial Hospitalization Program (PHP) or an Intensive Outpatient Program (IOP) that incorporates DBT.
If you would like your teen to continue receiving Dialectical Behavior Therapy after they have successfully completed the IOP/PHP, your primary therapist and discharge coordinator can give a referral to a local outpatient DBT program. An outpatient DBT program usually provides one skills-training class per week and between-sessions phone coaching, in addition to the weekly individual/family therapy session.
When the selection of programs in your area is lacking or offers limited availability, your discharge coordinator should try and locate a private outpatient DBT therapist near you. That way, your teen can continue their skills-training groups, phone coaching, and individual sessions once a week.
Either way, before your son or daughter leaves the teen treatment program, their primary therapist will work with them to prepare for their new life situation and review the specific DBT skills (e.g. “Coping Ahead”) that may pertain to their new reality.
Which Level of DBT Care is Best for my Teen?
Whether it’s residential treatment, IOP or PHP, get in touch with a Dialectical Behavior Therapy program for teens today. Let your child start building, as they say in the DBT world, a life worth living.