Marsha Linehan developed dialectical behavior therapy (DBT) in the early 1990s specifically for the treatment of borderline personality disorder. DBT is a multifaceted treatment approach that includes facets of cognitive behavior skills training, mindfulness meditation, behaviorism and dialectics. Though none of these individual aspects is novel on its own, implementing them together in a structured program was an innovative development that has led to greater client success.
DBT is structured to help clients gain insight and skills to manage their thoughts, emotions and behaviors. Per Linehan’s guidelines, the format is intensive, involving a two-hour weekly psychoeducational skills group, one hour of individual therapy each week, weekly skills homework and phone coaching between sessions. The therapy focuses on four skills modules:
- Mindfulness: Teaches mindfulness meditation
- Emotion regulation: Educates clients on emotions and how to manage them
- Interpersonal effectiveness: Teaches skills to help clients manage healthy relationships
- Distress tolerance: Teaches skills to help clients deal with emotional crises
Therapists engage the client dialectically, working to incorporate interventions to validate the client while facilitating client change. Linehan dialectically posits that clients are doing the best they can but also need to do better. Therapists also use behavioral interventions to reinforce the use of new skills and positive coping, while working not to reinforce old, maladaptive ways of coping.
Adaptations for adolescents
After several randomized, controlled trials proved DBT’s effectiveness in decreasing symptoms related to borderline personality disorder, studies have been conducted with several other populations and diagnoses, including substance dependence, eating disorders and mood disorders.
Preliminary research suggests DBT also can be effective in treating adolescents, likely because many adolescents struggle with symptoms that mirror those found with borderline personality disorder, including nonsuicidal self-injury, suicide attempts, dichotomous thinking, impulsive behaviors, labile moods and unstable interpersonal relationships. Current research shows that among adolescents, those struggling with these symptoms, including adolescents who have been diagnosed with an Axis I disorder, have a previous history of noncompliance in treatment and have significant difficulties regulating their emotions, will benefit most from a DBT program.
In their 2007 book Dialectical Behavior Therapy With Suicidal Adolescents, Alec L. Miller, Jill H. Rathus and Linehan developed several adaptations to traditional DBT for use with adolescents. Although the involvement of the support system is important when using DBT with adults, the involvement of parents and guardians when working with adolescents is even more important. When parents learn the skills their children are learning, parents can model these skills at home and also use the skills to facilitate their own coping. Family involvement can also be an important aspect of treatment compliance. Optimally, therapists will offer skills training groups for family members, either in conjunction with the adolescent’s skills training, separately or some combination of both. In addition, individual family therapy can be implemented as needed, as can between-session phone coaching for the parents as well as the adolescent. At the very least, support from family members is crucial to DBT’s effectiveness with adolescents.
Miller, Rathus and Linehan also included the addition of a fifth module, “Walking the Middle Path.” This module teaches the concept of adolescents and their parents thinking and acting dialectically, as opposed to thinking and behaving in extremes. The module includes common “dialectical dilemmas” — for example, when parents and adolescents vacillate between being too strict or too lenient with expectations and boundaries. Another aspect involved in this module is validation — specifically, teaching adolescents and parents how to validate their own thoughts and feelings as well as the thoughts and feelings of others.
When implementing DBT into any setting, regardless of the population, clinicians need to consider whether it would be best to implement full DBT or an adaptation of DBT. For example, many clinicians introduce only the psychoeducational skills group if limitations may keep them from implementing individual DBT treatment or the phone-coaching element. Studies have tracked the use of DBT in various settings, including inpatient units, outpatient settings, intensive outpatient programs and schools. Adaptations are often needed to fit the time frame and population involved at each site, however. If clinicians decide to implement only the DBT skills groups for adolescents, Miller, Rathus and Linehan suggest keeping the groups as homogeneous as possible, taking into consideration age, diagnosis, symptoms and gender. In addition, it may be best to exclude clients struggling with psychosis, mania, developmental disabilities and severe substance abuse from these skills groups. These are suggestions, however, and published studies have detailed the use of DBT with clients with developmental disabilities, substance dependence and other severe disorders.
Specific DBT skills
Many DBT skills can be implemented easily into current treatment approaches and programming with adolescents. I will give a brief overview of a select few, but these skills — as well as several others — are covered in more depth in the resources listed at the end of this article. Many of these resources include handouts and homework assignments for clinicians to use in treatment.
One of the main facets of DBT is mindfulness. In DBT, mindfulness is used so clients can activate their “wise mind” — the dialectic between their emotional mind (when all thoughts and behaviors are controlled by emotions) and their reasonable mind (the thinking, logical side). The wise mind is often considered intuition, and activating the wise mind via mindfulness is the key to effective decision-making.
Mindfulness is not necessarily limited to sitting quietly and controlling one’s thoughts. Any activity can be considered mindful as long as the client is in the moment, observing, describing and participating — mindfully, nonjudgmentally and effectively. Some nontraditional DBT group mindfulness activities include singing “Row, Row, Row Your Boat” in a round while performing hand movements, engaging in a silent exercise in which one partner mirrors the other partner’s movements exactly, or putting a dab of toothpaste on one’s nose and being mindful of the experience.
It may be difficult to engage adolescents with certain mindfulness activities in a group setting, especially in the beginning or when one or two group members balk at the idea of doing something that might make them look silly in front of their peers. In such instances, I encourage group members to be mindful of the thoughts and emotions they are experiencing in that moment that make them reluctant to engage in the activity. This exercise often elicits further discussion.
For practice outside of the group, I suggest that clients engage in mindfulness activities while doing the dishes, driving or washing their hair. As long as they are in the moment and focusing on that one activity, they are engaging in mindfulness.
Another skill that can be particularly helpful for adolescents is the use of an acronym, DEAR MAN, taught in the interpersonal effectiveness module. Adolescents can put this skill to use when they wish to ask for something they want or when they need to say “no.”
The acronym is as follows: Describe the facts of the situation; Express your feelings and opinions surrounding the situation; Assert what you want; and Reinforce to the other person why this will be helpful to both parties or to the relationship. Clients will do this by staying Mindful and ignoring any verbal attacks; Appearing confident while doing so; and being willing to Negotiate if needed.
It can be helpful to elicit examples from the group. One example that came up was when a friend constantly borrowed a client’s clothes and did not return them. To discuss this issue with her friend using the acronym, the client would:
- Describe the situation (“I frequently lend you my clothes, but you do not return them after I ask you to”)
- Express her feelings (“I feel hurt and angry when you do not return my clothes”)
- Assert her wants (“I would really appreciate it if you would return my clothes when I ask”)
- Reinforce why her friend should comply with her request (“I would feel better about our friendship and will not feel resentful toward you”)
After that, the client will:
- Stay Mindful, ignoring any side attacks (for example, the client’s friend might point out that she never calls her back; the client needs to ignore this and stay focused on her goal)
- Appear confident (being sure not to be overly aggressive or overly passive)
- Be willing to Negotiate (“I am willing to remind you once to return my clothes if you will agree to return them when I remind you”)
Adolescent clients enjoy pairing up in group and practicing the application of this acronym in role-plays. Practicing the skill beforehand will help prepare clients to use the skill outside of session.
One of my favorite DBT skills is radical acceptance. In the distress tolerance module, this skill can help clients cope with a situation they find particularly upsetting so they can then determine what they have control over in the situation. Linehan encourages clinicians to introduce this skill by telling clients that although pain is a part of life, we suffer only when we refuse to accept that pain. By not accepting reality in a situation that is particularly upsetting or painful, we suffer. Thus, we must radically accept reality, even when it is difficult. For adolescents, this reality might be receiving a bad grade on a test, finding out a friend said something bad about them behind their back or being grounded for what they consider to be an unreasonable amount of time.
One example I use is receiving a cell phone bill that is much higher than I expected it to be. No matter how angry and upset I am or how much I curse my cell phone provider for charging me 10 cents per minute, until I accept the fact that I have received this bill, there is nothing I can do about it. Once I accept the reality that I have received this bill, then I can decide whether to call the customer service number and try to negotiate a reduction in my bill. Or, in the examples mentioned above, once the adolescent accepts the reality in those situations, she can decide whether to discuss the grade with her teacher, confront her friend and communicate her concerns to her parents.
Clients may have difficulty “accepting” reality, especially when the event is particularly hurtful or sad, or if they feel it is unfair. It is important to emphasize to clients that accepting the situation is not the same thing as agreeing with it or saying it is “right.” Rather, they are simply reducing their suffering by accepting reality as it is instead of how they wish it was or how it “should” be. When clients are first learning radical acceptance, Linehan suggests using a different term, such as endure, to help them get past the feeling that they are condoning the situation by accepting it.
I have often had clients who felt they did not need to accept the reality of a particular situation — for example, the death of a loved one. In these instances, I have redirected them to radical acceptance of each aspect of the situation, including the grief that comes along with a difficult loss, the desire not to accept that loss and the time needed to heal from this loss.
Conclusions and resources
DBT is a complex and multifaceted treatment, but clinicians can choose the aspects of DBT they believe will be most helpful to clients on the basis of the client’s age, diagnosis and situation. Although DBT originally was developed for the treatment of borderline personality disorder, research has spread that seems to support its use with a variety of diagnoses and populations. It should be noted, however, that most of the research on these populations is preliminary, and the use of evidence-based treatments for the population with which a counselor is working should be the primary consideration when implementing interventions.
The full 10-day DBT training is offered only to treatment teams through Behavioral Tech (behavioraltech.org), the organization founded by Linehan and her associates for DBT training and resources. However, Behavioral Tech also offers shorter and more specialized trainings for individuals. In addition, many organizations and DBT therapists will offer trainings locally. Furthermore, many texts are available on the topic, including the following resources that I have found helpful.
- Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings edited by Linda A. Dimeff and Kelly Koerner, 2007
- Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha M. Linehan, 1993
- Skills Training Manual for Treating Borderline Personality Disorder by Marsha M. Linehan, 1993: This text includes all of the skills handouts for each module and guidelines for implementing a psychoeducational skills group.
- Dialectical Behavior Therapy With Suicidal Adolescents by Alec L. Miller, Jill H. Rathus and Marsha M. Linehan, 2007: This is a good resource if you’re interested in implementing DBT with adolescents.
Knowledge Share” articles are based on sessions presented at American Counseling Association Annual Conferences.
Karen Michelle Hunnicutt Hollenbaugh, a licensed professional counselor, is an assistant professor in the Department of Counseling and Educational Psychology at Texas A&M University-Corpus Christi. She has spent several years practicing and engaging in research involving DBT. Contact her at Michelle.Hollenbaugh@tamucc.edu.
Letters to the editor: firstname.lastname@example.org