Dialectical Behavior Therapy (DBT) can be a very effective treatment for teenagers who are living with anxiety, depression, self-harm, suicide ideation, social skills issues, and many other problems.1,2,3 A typical DBT program is focused on learning specific skills, and is typically six months to a year in length.
What Is DBT?
Dialectical behavioral therapy (DBT) is a therapy that is based on the idea that people struggle due to a mix of biology, lack in skills, and invalidation in their lives.4 Therefore, DBT creates success for teens through teaching skills and providing supportive validation.5,6
What makes DBT unique is that it was one of the first therapies to balance acceptance and change, rather than focusing primarily on just one or the other. This balance of acceptance and change provides the support and motivation someone needs to learn the skills they are lacking, in order to make the changes they need.
The original model of DBT incorporated skills training classes, individual therapy, phone coaching, and therapist consultation meetings:4
- Skills training is the method in which individuals learn how to make change.
- Individual therapy supports the learning of skills, provides time to troubleshoot learning, provides much-needed validation, and models a healthy relationship.
- Phone coaching are short calls to support use of skills in the moment.
- Therapist consultation provides a space for therapists to discuss cases to ensure they are providing the best therapy possible.
However, DBT has been successfully modified for many populations and settings. When beginning a new DBT program, the therapist will provide orientation materials that will discuss their particular program.
How Is DBT Adapted for Teens?
DBT for teens differs from DBT for adults in several key ways, and there is a research-validated program for those changes called DBT-A (DBT for Adolescents).6
The Involvement of Caregivers
The most significant difference of DBT for adolescents is the inclusion of caregivers. Oftentimes, caregivers will be included in skills training sessions or may have their own separate skill training sessions. Caregivers will also be part of individual therapy at times or be included through additional family sessions. Therapists provide phone coaching to the caregivers in addition to the adolescent. Caregiver involvement is a critical piece of getting the most improvement.7
DBT Skills for Teens: Walking the Middle Path
DBT for adolescents includes a new skill module, Walking the Middle Path, that is included in the skill training rotation. Walking the Middle Path addresses issues that arise within the family that can undermine treatment. This module emphasizes teaching dialectics, validation, and behavior change. Focus on these skills teaches caregivers and their adolescents the skills needed to decrease conflict. It also provides a common language for families to work through issues using a common language.
Mindfulness of Age & Development
DBT Therapy for teens also must take into account an adolescent’s developmental stage. Therapists providing therapy to teens will often shorten the group session length in comparison to adults to accommodate the shortened attention span.
Groups and individual therapy may also be more hands-on or rely more on the use of metaphor and examples. Skilled therapists will also be aware of how adolescent developmental tasks differ from adult developmental tasks and incorporate their understanding into the issues being treated.
Types of DBT for Teens
The needs of teens vary greatly, and DBT has been adapted to meet the level of care an adolescent may need. The levels of care range from non-clinical applications in school for general skill-building, through high levels of care in a hospital, to maintain safety. A therapist or psychiatrist will assist in determining the right level of care for a teen.
Outpatient DBT
Outpatient therapy is the traditional and most common method of delivering DBT therapy, but can still take many variations.4,6 For some people, skills can be taught during individual therapy if they are not successful in a group setting or the agency does not provide groups.
Outpatient therapy may also provide the full model with skills training groups, individual therapy, and phone coaching. New technology continues to be developed, and apps or online DBT options may be incorporated. Outpatient therapy is for teens who are struggling but are functional and safe enough between groups to not need higher levels of care such as some of the settings listed below.
Intensive Outpatient DBT
Intensive outpatient therapy will meet several times a week, often 3-5 groups per week. Depending on the program, outpatient therapy may be entirely DBT-focused, or DBT may be a portion of the program. With the higher frequency of groups, intensive outpatient therapy will frequently cover skills more than once, or cover them more rapidly, and may incorporate more review, processing, and troubleshooting into groups. Intensive outpatient therapy is frequently for those at risk of inpatient hospitalization or are exiting a higher level of care.
Residential Treatment and Inpatient Treatment
Residential and inpatient treatment programs both have the teens on-site for the entire day, which offers many potential variations and creativity for delivering DBT. Depending on the length of the residential program and program design, an adolescent may be exposed to the entire sequence of DBT skills during their time in the program.8
A residential program may also choose to focus on a smaller selection of skills and ensure they are well learned and able to generalize to life outside of residential treatment. Oftentimes, individual therapy will be a component of the treatment in residential, as well. DBT will likely offer indirect influence to other groups, behavior management, and interactions with staff.
Inpatient treatment tends to be shorter in length and will modify DBT even more than residential treatment. Inpatient programs frequently use a smaller set of DBT skills, often focusing on distress tolerance and emotion regulation skills. The exposure to DBT in an inpatient setting is more of an introduction or “boot camp” approach and should be reinforced in outpatient treatment after discharge from the hospital.
DBT for Cognitive Impairment
Finding effective treatment for individuals with cognitive impairments can be difficult and DBT has been adapted to help fulfill that need.9 The adaptation was designed for adults with cognitive impairments but a savvy therapist will be able to make further adjustments to treat a teen. The language and treatment design have been simplified for easier understanding. The adaptations include concrete and easy-to-understand terms, more visuals, and more enticing worksheets. The structure of the group is also modified to accommodate different learning styles.
DBT Courses in Schools
Schools are now beginning to offer DBT programs as classes or groups, called DBT STEPS-A.10 The program designed for schools is a non-clinical application. A non-clinical program is for any student that could benefit from the skills but does not necessarily have any mental health diagnosis.
The school program is entirely skills-based, eliminating the other components of a DBT program, and can be offered by a non-clinician. However, some schools now have therapists embedded in the school and may offer a DBT program similar to the outpatient methods.
Common Techniques & DBT Skills for Teens
Although there are many DBT techniques used with teens that may vary across programs, there are several common techniques or tools you will likely see. The techniques you see in adolescent programs are a mix of techniques that are core to DBT and techniques that are important for use with teens.
Some common DBT techniques and skills used with teens include:
- Mindfulness: Mindfulness is a core component of any DBT program and teaches individuals to be present and aware in the moment. Being aware and present allows a teen to tolerate more, and be able to use tools to make change.
- Radical self-acceptance: Radical acceptance is an offshoot of mindfulness and teaches a teen to fully accept what is or has happened in life. Radical does not mean being ok with any situation, but it frees one from fighting reality.
- Walking the Middle Path: Walking the Middle Path is a collection of emphasized techniques to assist with common teen issues. The emphasized techniques include dialectics, validation, and behavior change.
- Dialectics: Dialectics is recognizing and honoring two different sides of a conflict to find the common truth between them. For example, someone can be doing the best they can and yet need to do better.
- Validation: Validation is recognizing that someone else’s experience, and your own experience, are important. Even when there is disagreement, validation honors actions, feelings, and thoughts.
- Behavior Change: Behavior change is a collection of techniques that helps motivate, make, and maintain desirable changes in behavior.
Examples of DBT for Teens
The formalized adaption of DBT for teens is still relatively new. Therefore, research is still exploring specific modifications for adolescents with specific diagnoses or needs. Certain programs may be making their own adaptations that are not yet supported by research.
That said, it is still a new field and those programs making modifications are pioneers, and may still get incredible results. If you are concerned, you can always ask a program for their data on outcomes. Research has found promising outcomes for DBT adaptations for some of the diagnoses and issues below.
DBT for Teens with Depression, Anxiety, Self-Harm, and Suicide Ideation
The basis for much of the information discussed thus far comes from the DBT-A program, which was specifically created to address issues of depression, anxiety, self-harm, and suicide ideation.6 Teens struggling with these issues will frequently present with lowered motivation, decreased interest in activities, a decrease in grades, disrupted social interactions, risky behavior, self-harm, thoughts of suicide, or suicide attempts. Programs will always address issues of safety first. Next, they will address any issues that will interfere with treatment before moving onto improving quality of life and gaining skills.
The DBT-A program is designed for a 16-week length of time. However, there is an option for a graduate group that runs another 16 weeks to go review and lock in skills. Depending on the severity of symptoms upon entering treatment, the course of these groups may be sufficient to end treatment upon completion.
If the severity of issues were high at the beginning of treatment, or if anything interfered with the treatment process, a teen may need to continue treatment afterward. The aftercare plan could be a return to traditional outpatient therapy or other programs that are offered in your area.
DBT for Bipolar Disorder
There has been some limited research suggesting DBT can be an effective intervention for teens with forms of bipolar disorder.11,12 The protocol used with the adolescents was very similar to the traditional DBT-A program with few additions.
The first significant addition to the program was a module on psychoeducation about bipolar disorder and DBT treatment. Researchers also highlighted three components of emotional vulnerability including reactivity, intensity, and duration of affective responses.
Therapists were then able to tie specific mood states to skills and goals for that mood state. Special emphasis was placed on assisting teens in identifying their mood state and choosing appropriate skills to address the mood. Outside of the scope of DBT, the teens also had monitored psychopharmacology interventions.
The treatment that was created for adolescents with bipolar disorders was a two-part program. Each part of the program ran for six months. The initial six months included weekly therapy alternating between individual therapy and family therapy for a total of 12 sessions each. The second part of therapy, the maintenance phase, cut that number in half with 6 sessions of each. As always, at the completion of the course of treatment, the therapist guided clients on discontinuation of therapy or further therapy options.
DBT for Eating Disorders
Research has shown some effectiveness in treating eating disorders with DBT among adults.13 Although still in its infancy, research on treating eating disorders with DBT among teens shows promise.14 The research done by Pennell was conducted in a day treatment program in Canada.
Adaptations to treat eating disorders included directly addressing the invalidating environment of cultural pressures on body image. Daily monitoring of goals and symptoms on diary cards was modified to include food intake and eating disorder-specific behaviors. As with other adolescent adaptations, there was a strong emphasis on caregiver support.
This program combined DBT with Family-Based Therapy. Parent support was mandated in this program, as was a minimum six-week commitment. When looking for a program treating eating disorders with DBT, you will likely find great variation in program length and components based on the program’s emphasis.
Is DBT for Adolescents Effective?
Although adaptations of DBT for teens are still relatively new, the research thus far has continually shown positive outcomes. The pioneers in researching DBT with adolescents are Miller and Rathmus, the developers of DBT-A.6 The DBT-A adaptation has been endorsed by Marsha Linehan, the developer of DBT.6
Meta-analysis reviews and research by others continue to find positive outcomes of DBT for teens.1,2 Additional research supports the use of DBT in residential treatment, inpatient treatment, juvenile corrections, and many other contexts.15,16,17
Research will continue to develop new adaptations and improve the knowledge base on current adaptations. The Linehan Institute is the strongest driver of further research. In addition, many universities, within the US and internationally, continually produce new research about DBT.
How to Find a DBT Therapist for Your Teen
If you are looking for a DBT therapist for your teen, start by contacting your insurance company. Your insurance company will have a list of covered therapists and agencies. Most agencies and therapists will list the therapies in which they’ve been trained, including DBT. Many therapists have received training in DBT through thorough seminars, are very talented, and will list their DBT experience.
However, if you want a therapist that is certified in DBT, The Linehan Institute maintains a list of therapists credentialed in DBT. Always feel free to ask for further information on an agency’s or therapist’s experience with DBT to determine if it is a good fit for you.
At-Home DBT Exercises for Teens
Whether you are waiting to get your teen into treatment or looking for some ideas from DBT to incorporate at home, here are a couple of techniques you can try:
Validation
Slow down and listen to what your adolescent is saying, doing, or feeling. Try to look at it through their eyes and experiences. Whether you agree or not, try to find something understandable and let them know. For example, if your teen is experiencing a breakup and feels their life is over, try saying something like “This really sucks! You were so in love!” Saying something like this lets your teen know you understand them and will open them up to listening more.
Starting with something like “You’ll get over it! You’re just a teenager” does not validate their experience and often ends in an argument. Here’s the trick: Start with validation and you might still be able to help them see the perspective that they are just a teenager and their life will not end. If you don’t know what to say, just ask more questions and be curious. This is also very validating!
Accumulate Positive Experiences
When things are difficult, it is easy to focus on everything that is not going well. It is natural to put energy towards fixing what isn’t working. However, humans also need positive experiences to balance the negative. Work with your teen to set aside time for things they enjoy or that you can enjoy together. The positive experiences should be islands of good energy, free from consequences for negative behavior. In this way, they will not lose the balance they get from those positive experiences. So, choose carefully!
