If you have a child with psychiatric or behavior problems, there’s a good chance you’ve heard of mindfulness and cognitive behavioral therapy (CBT), two different approaches to helping kids with everything from test anxiety to depression. But there’s another very promising therapy that combines elements of both. DBT, or dialectical behavior therapy, is an intensive, highly structured program that’s been adapted specifically for adolescents with extreme emotional instability, including self-harm and suicidal ideation.
The “dialectical” in DBT means the therapy works by dealing with two things at once that might seem contradictory: acceptance of feelings (mindfulness) and learning to use thinking to change feelings (CBT). It’s basically “‘I’m doing the best I can’ on the one hand,” notes Dr. Alec Miller, professor in the Department of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine “and ‘I need to do better.’ That’s a dialectical truth.”
A brief history of DBT
Dialectical behavior therapy was developed by Dr. Marsha Linehan in the 1970s to treat adult borderline personality disorder — a mental illness with symptoms ranging from chronic suicidal thoughts and/or self-harming behaviors to anxiety and depression. These patients were typically thought of as “difficult,” if not impossible, to treat. Dr. Linehan redefined the disorder, reframing it as a specific problem of the emotion regulation system that can be addressed with a structured intervention.
People with borderline personality disorder have trouble regulating their moods, which leads to impulsivity and conflict in interpersonal relationship. That, in turn, often leaves them feeling misunderstood by others around them. First, Dr. Linehan tried traditional CBT, which emphasizes using conscious thoughts to confront and change problematic emotions. She was unsuccessful with her patients. So she then tried a much more acceptance-based approach that came out of her meditation and mindfulness practice. This, too, failed.
“So then she had this brilliant epiphany,” says Dr. Miller. “Blending the acceptance strategies of mindfulness with the change technologies of CBT to create this dialectical behavior therapy.”
How Does DBT Work?
DBT treatment is designed to help with extreme emotional instability, which clinicians call “dysregulation” — the inability to manage intense emotions. Dysregulation leads to impulsive, self-destructive, or self-harming behaviors. The goal of DBT is to teach adolescents techniques to help them understand their emotions without judgment — the mindfulness component — and also to give them skills and techniques to manage those emotions and change behaviors in ways that will make their lives better. But it takes work and commitment.
DBT for adolescents involves individual therapy and group skills training, where parents and teenagers learn together. The feedback from parents, says Dr. Jill Emanuele, a clinical psychologist at the Child Mind Institute, is, “Where have these skills been all my life? I need these skills too.” Other components include telephone consultation (patients are encouraged to call their therapists when they feel the urge to self-harm), family therapy, and weekly consultation team meetings where the therapist checks in with other professionals to consult on the case.
What skills does DBT teach?
DBT skills training is very structured; for adolescents, it consists of five modules:
- Mindfulness skills: Being present in the moment and understanding the signs of unregulated emotions
- Emotion regulation skills: Coping with difficult situations by building pleasant, self-soothing experiences to protect from emotional extremes. “Especially with teenagers,” says Dr. Emanuele, “there’s a big focus on the physical body: eating properly, getting enough sleep, taking their medicine and avoiding drug use.”
- Interpersonal effectiveness skills: “It’s often interactions with others that are the negative triggers for impulsive behaviors,” Dr. Emanuele says. The purpose is to teach adolescents how to interact more effectively with others, and enable them to feel more supported by others.
- Distress tolerance skills: “It’s being able to recognize urges to do things that would be ineffective, such as hurting themselves or trying to kill themselves” and consciously controlling them, says Dr. Emanuele.
- Walking the middle path skill: Kids and parents learn how to validate one another, how to compromise and negotiate, and how to see the other person’s side of things. “It has to do with acknowledging multiple truths in the teenagers’ and the parents’ worldview as opposed to ‘I’m right and you’re wrong,’ ” explains Dr. Miller.
What is DBT used to treat in adolescents?
Borderline personality disorder was historically considered something that could not be diagnosed in a person under the age of 18. But many clinicians, including Dr. Emanuele and Dr. Miller, now feel that symptoms of the disorder do develop in some adolescents, and the debilitating roller coaster of extreme emotions that they experience can be effectively treated with DBT.
DBT has also proved effective in treating the emotional instability and severe behavioral symptoms — self-harm and suicidal thoughts or attempts — seen in adolescents with other diagnoses, including:
- Drug abuse
- Eating disorders
- Bipolar disorder
- Disruptive behavior disorders
“DBT,” says Dr. Emanuele, “is used to treat adolescents with multiple problems that often include suicidality or self-harming behaviors. The keyword here is multiple.”
DBT: An adolescent’s perspective
Rachel Monasch did not have it easy as a kid. When she was little her mother’s chronic illness kept her in the hospital for long stretches of time. She developed severe anxiety early on in life and had trouble making friends at school. Eventually she developed an eating disorder and at 13 she began to hurt herself. At 15, Rachel says, “I had I guess what you’d call a breakdown. I spent most of the year out of school.” Rachel had been in therapy for a long time but it was mostly unstructured talk therapy along with medication. When she began struggling with suicidal thoughts she was hospitalized in an adolescent unit at a hospital that she describes as horrifying and traumatic. “I was assaulted by another patient and they didn’t do anything.” Rachel says she came out more depressed than when she went in.
But then she switched to a therapist who specialized in DBT. That clinician got her enrolled in a 28-day DBT “boot camp” for adolescents that also had an eating disorders program. “We learned and practiced DBT all day, every day, for 28 days,” she says. Now, a year later, Rachel is doing very well. She finds some of the tools she learned in DBT more helpful than others, so that’s where she focuses her energy. “Distress tolerance, mindfulness, and emotional regulation skills are the big ones for me,” she says. “I don’t fight with people or even really my parents so the interpersonal effectiveness skills aren’t all that helpful to me.”
Rachel relies heavily on diary cards — daily logs that track her moods and emotions, what triggered them, how she reacted to them both positively and negatively—and the collection of skills she has come up with to deal with uncomfortable emotions. She has 19 so far. She also does a lot of breathing to center herself.
According to Rachel’s dad, “DBT saved her life.” But Rachel says it’s not quite that simple. “I would say lithium plus DBT and a great therapist saved my life.”