Dialectical Behavior Therapy With Suicidal Adolescents

suicidal teenager

Dialectical behavior therapy is a form of cognitive behavioral therapy (CBT). Marsha M. Linehan developed DBT in the late 1980s. It was originally developed as a treatment method for suicidal individuals struggling with borderline personality disorder (BPD). Borderline personality disorder is a severe mental health illness. It is listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and is characterized by unpredictable moods and behaviors and a long-term pattern of unstable relationships. Evidence has shown that dialectical behavior therapy has also become useful in treating individuals with other mental health ailments (e.g. eating disorders, depression, bipolar disorder, substance abuse, etc.). Nowadays, DBT is more widely known an evidence-based form of psychotherapy that is intended to help individuals who have difficulty with emotional regulation and/ or are exhibiting self-destructive behaviors.

DBT Overview

Dialectical behavior therapy is conducted in three different therapeutic settings, each with distinct goals. DBT includes weekly individual therapy sessions, weekly group DBT skills sessions, and phone coaching (between sessions) when needed. The individual therapy sessions provide one-on-one support where an individual can go over any challenging situations that have arisen throughout the week as well as enable the individual review the lessons learned in the group skills sessions. The phone coaching allows a young person twenty-four hour access to support between sessions, should crisis arise. DBT group skills sessions focus on four skill modules, which include the following:

  • Core mindfulness: this area focuses on improving an individual’s ability to accept and be present in any given moment. The skills in this module help individuals learn to the importance and value of slowing down and taking pause instead of succumbing to intense emotions and acting in destructive ways. 
  • Distress tolerance: focuses on increasing an individual’s tolerance of negative emotion as opposed to attempting to avoid or escape from it. The skills in this module help individuals learn various techniques for handling crisis (e.g. distraction, self-soothing, improving the moment, etc.). 
  • Emotion regulation: focuses on helping an individual identify, name, understand the function of, and regulate their emotions. The skills taught in this module are intended to help an individual learn to decrease the intensity of their emotions, sit with and experience strong emotions that are causing problems in one’s life, without impulsively acting on them.
  • Interpersonal effectiveness: focuses on increasing individual’s communication strategies. The skills taught in this module help an individual learn to identify what their own needs are in a relationship and develop assertive and effective communication methods to ensure those needs are met in a healthy way. 

The entire DBT program typically lasts about six months long, as six weeks are allocated to focusing on each of the four DBT skills modules. There are some partial options that focus only on certain modules, which would reduce its overall duration. Depending on the needs of the individual, there are some longer options that repeat each module, doubling the time it takes to complete the program. 

Suicidal Teens

Adolescence is a stage in one’s life that is filled with immense growth. It is a time when young people are faced with countless lessons to help prepare for the future and learn the tools needed to effectively navigate adulthood. It is to be expected that teens will experience a wide range of emotions, including extreme sadness, frustration, and even despair at some points in their youth. However, it is imperative to seek professional guidance in situations where a teenager’s emotions become so overwhelming that he or she becomes suicidal. The combination of the four DBT skills modules help a young person learn to acknowledge, accept and learn from difficult emotions that arise and experiences that occur throughout one’s life. DBT also helps an individual learn to communicate in an authentic and assertive fashion that can help improve relationships and simultaneously increase one’s sense of self-worth.

What Is The Criticism Of DBT? 

criticizing DBT therapy

Dialectical behavior therapy, also known as DBT, is a form of psychotherapy that is founded on the principals of cognitive behavioral therapy (CBT). Psychologist Marsha M. Linehan developed DBT in the late 1980s as a means to help better treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD). Although touched upon in cognitive behavioral therapy, DBT places primary emphasis on the psychosocial aspects of treatment. DBT combines standard CBT techniques for emotional regulation and reality testing with concepts derived from Buddhist meditative practice such as awareness, mindfulness and attentiveness to current situations and emotional experiences to encourage acceptance. 

The Basics of DBT

Dialectical behavior therapy is comprised of three distinct therapeutic settings, including weekly individual psychotherapy (one-on-one therapy) sessions; weekly DBT skills group sessions, and access to twenty-four hour support between sessions via phone coaching, when needed. The group skills sessions focus on teaching four sets or modules of behavioral skills, which include: 

  • Mindfulness: focuses on improving a person’s ability to accept and be present in the current moment.
  • Distress tolerance: focuses on increasing an individual’s tolerance of negative emotion instead of trying to avoid or escape from it.
  • Interpersonal effectiveness: focuses on communicating with others in a way that maintains self-respect and strengthens relationships
  • Emotional regulation: focuses on strategies to de-escalate charged emotions.

Homework is often assigned after each group skills sessions to help further facilitate understanding the information taught. The one-on-one therapy sessions provide an individual with the opportunity to go over and learn from his or her diary card. The purpose of a diary card is to track emotions, identify which DBT skills were used and determine if the skills used were effective throughout the week. The therapist will provide support and guidance related to areas of struggle illuminated from one’s diary card, so as to help the individual pinpoint exactly where something may have taken an unproductive turn and avoid a repeat incident. The entire DBT program takes around six months to complete, as six weeks are allocated to each module. Longer DBT programs may elect to repeat the skills modules, going through them twice, which would extend the length of the program to last about twelve months long. 

Critiques of DBT

Although DBT was initially developed to treat individuals diagnosed with borderline personality disorder, it has since become an effective treatment method for other mental health illnesses. As DBT has become a mainstream mental health treatment option, various criticisms have been brought to light. Some individuals that could benefit greatly from dialectical behavior therapy view it as overly complex to the point that they are unwilling to try the treatment. According to the U.S. Department of Veterans Affairs, due to the fact that DBT does not necessarily involve any form of trauma processing, it is not and should not be considered a stand-alone treatment for trauma. The foundation of DBT is rooted in mindfulness practice based on Zen Buddhist teachings. Hence, some conservative Jews, Christians or Muslims may object to certain facets of DBT derived from Eastern religious philosophies. 

Every individual is different and will have unique needs when it comes to mental health treatment. Although DBT has been found to be an effective treatment method for BPD, it does not mean DBT will necessarily resonate with every single individual diagnosed with borderline personality disorder. The same is true for individuals diagnosed with other mental health disorders: this form of treatment may be effective for some and ineffective for others. 

What Are The Four Areas of DBT?

teen before DBT

Dialectical behavior therapy (DBT) is type of psychotherapy (talk therapy) based off of the cognitive behavioral therapy (CBT) approach. DBT further emphasizes the psychosocial aspects of treatment. Psychologist Marsha M. Linehan developed DBT in the late 1980s as a means to more effectively treat individuals diagnosed with borderline personality disorder (BPD). Since it was developed, research has found it to be not only highly effective in treating individual with BPD, but also a successful treatment method for individuals experiencing other mental health illnesses (e.g. eating disorders, post-traumatic stress disorder, generalized anxiety disorder, depression, substance use disorder, etc.). The purpose of DBT is to provide clients with new skills to manage painful emotions and reduce conflicts in relationships. The therapeutic approach consists of three different therapy settings, including weekly individual psychotherapy sessions, weekly group DBT skills therapy sessions, and phone consultation to provide additional support between the weekly individual and groups sessions (when needed). DBT is made up of four distinct modules, with roughly six weeks specifically allocated to focus on each area. The entire dialectical behavior therapy process usually takes around six months to complete. 

  1. Core Mindfulness: Focusing Skills

This module focuses on teaching an individual how to focus their mind and attention. Through learning and practicing the DBT mindfulness skills, individuals are able to focus on the present and tend to what is exactly happening in any given moment. Skills during this module help individuals learn and practice slowing down to focus on mindfully acknowledging and experiencing emotions without reacting impulsively and/ or destructively. It teaches individuals to avoid taking things personally, glean a better understanding of their emotions, become active listen listeners and learn to sit with emotions instead of pushing them away. 

  1. Distress Tolerance: Crisis Survival Skills

The purpose of the distress tolerance module is to help individuals learn tools and techniques to get through challenging times when emotions are elevated. Rather than becoming overwhelmed by or hiding from difficult emotions, it teaches individuals four sets of crisis survival skill to assist in finding meaning in, accepting and tolerating distress, some of which include self-soothing, distracting, and thinking of pros and cons. Learning these skills help an individual learn to acknowledge, process, and integrate emotions and situations in a non-evaluative and nonjudgmental fashion. 

  1. Emotion Regulation: De-escalation Skills

This module teaches important skills surrounding emotional regulation, as well as providing education regarding the function of emotions. It helps individuals learn to both experience strong emotions while simultaneously reducing the intensity of the emotions without acting on them. In this module individuals will learn a variety of helpful skills including, but not limited to: properly identifying and labeling emotions, increasing positive emotional events, increasing mindfulness to current emotions, identifying obstacles to changing emotions, and applying distress tolerance techniques. 

  1. Interpersonal Effectiveness: Social Skills

This module teaches skills to help individuals learn how to effectively and authentically communicate with others. These skills involve helping individuals identify and understand their own needs in a relationship. Further, these skills help an individual learn various tools to help in facilitating and engaging in healthy relationships with others that enable one’s needs to be met. This includes advocating for one’s needs and communicating in way that is assertive, maintains self-respect, and strengthens relationships. 

Who Is DBT Aimed At?

images of feelings

Dialectical behavior therapy (DBT) is an evidenced-based psychotherapy approach, falling under the larger umbrella of cognitive behavioral therapy (CBT). CBT is often used in treating various mental health disorders (i.e. depression, post-traumatic stress disorder, eating disorders, etc.), however, research indicated that its effectiveness with individuals diagnosed with borderline personality disorder (BPD) was lacking. In the late 1980s, Marsha M. Linehan, who was at the time a psychology/ suicide researcher at the University of Washington, developed DBT to better treat chronically suicidal individuals and those struggling with BPD. The primary goal of DBT, according to Psychology Today, is to “transform negative thinking patterns and destructive behaviors into positive outcomes.” Although DBT was initially developed to treat individuals with BPD, it has become an effective and relied upon psychotherapeutic method in the treatment of other mental health conditions.

DBT Basics

DBT has a multifaceted approach as it includes individual psychotherapy sessions, group skills sessions, and phone coaching. Each therapeutic setting has its own structure and goals. There will often be out of session requirements (i.e. group skills homework) to help an individual continue to integrate and practice implementing the information learned into his or her daily life. The group skills sessions focus on teaching and practicing the four modules of DBT, which are: mindfulness (focusing skills), distress tolerance (crisis survival skills), emotional regulation (de-escalation skills), and interpersonal effectiveness (social/ relationship skills). Individual therapy sessions enable a client to process one-on-one issues that may arise during the group skills sessions’, clarify any confusion surrounding a skills assignment, and/ or practice personally applying and implementing the DBT skills to his or her own life. The phone-coaching component is intended to provide additional support should crisis arise between individual and group sessions. 

Who Could Benefit? 

Dialectical behavior therapy can help individuals that have a difficult time modulating strong emotions and/ or those that are emotionally vulnerable. The exact treatment plan developed for an individual struggling with a mental health disorder will depend on his or her specific needs. Many treatment plans will include a variety of therapeutic approaches, and in some cases medication. DBT remains the gold standard type of psychotherapy used for treating individuals diagnosed with borderline personality disorder who have thoughts of suicide and self-harm, but has also been noted as a potentially successful treatment option for other mental health conditions. The National Alliance on Mental Illness (NAMI) indicate that DBT may be an effective treatment for:

  • Bipolar disorder
  • Attention-deficit/ hyperactivity disorder (ADHD)
  • Generalized anxiety disorder (GAD)
  • Eating disorders
  • Obsessive-compulsive disorder (OCD)
  • Major depressive disorder
  • Substance use disorder
  • Post-traumatic stress disorder (PTSD)

Research has concluded that DBT can be effective regardless of a person’s gender identity, sexual orientation, age, and ethnicity/ race. DBT focuses on finding a balance in opposing forces. DBT places significant emphasis on learning how to accept and validate uncomfortable feelings, thoughts and/ or behaviors, instead of exerting energy on trying to push away, ignore, and/ or change discomfort. DBT empowers a client to learn applicable social and emotional skills, healthy coping mechanisms, and useful mindfulness techniques to enable a client to effectively cope with stress, live in the moment, regulate emotions, and improve relationships with others. 

How Long Does a DBT Program Last?

people holding hands

In the late 1980, Marsha M. Linehan developed Dialectical Behavior Therapy (DBT) as a therapeutic method to better treat individuals diagnosed with borderline personality disorder (BPD), suffering from pervasive suicidal thoughts and/ or attempts. It is currently recognized as an effective therapeutic method for treatment in a wide range of other mental health disorders, such as depression, anxiety, post-traumatic stress disorder (PTSD), substance use disorder (SUD), eating disorders, and more. The philosophical perspective of dialectics, balancing opposites, influences the DBT process. A mental health clinician offering DBT services works with an individual to identify ways to hold two seemingly opposite perspectives simultaneously. This, in turn, promotes balance and minimizes the tendencies to think in absolutes (i.e. viewing all in black and white, all-or-nothing style of thinking, etc.…). DBT encourages an inclusive worldview and perspective (both- and) instead of an exclusive (either- or) outlook on life. DBT is a specific type of cognitive-behavioral therapy (CBT) that greatly emphasizes the psychosocial aspects of treatment.

DBT Overview

The DBT process is comprised of group therapy, also known as DBT skills group sessions, and individual psychotherapy sessions. One-on-one therapy sessions are a helpful component of the DBT process as they can provide the individual in treatment with the opportunity to focus on his or her nuanced challenges. Individual therapy sessions can provide a forum to go over any confusion regarding DBT skills as well as process and improve problem-solving behaviors. The two types of structured sessions are held in conjunction with on another and compliment the different areas of focus, respectively. Though the general idea is for the individual in treatment is to attend the DBT skills group session and have a one-on-one therapy session weekly, the exact number of weekly sessions can be adjusted based in the specific needs of the individual. 

DBT Skills

The DBT skills group session make up an imperative component to the overall DBT program. DBT skills group sessions are focused on enhancing the capabilities of each participant by teaching behavioral skills. These group sessions offer participants an emotionally safe environment to practice implementing the DBT skills alongside others working on the same thing. Group members are encouraged to share their experiences and provide mutual support. DBT skills group sessions are usually held on a weekly basis and are conducted by a qualified mental health practitioner. DBT focuses on providing therapeutic skills in four areas that make up the pillars of DBT, which include the following:

  1. Mindfulness: the practice of being fully aware and wholly present in the current moment
  2. Distress Tolerance: learning tools and techniques to effectively tolerate pain that may arise from difficult situations, instead of attempting to avoid and/ or change it
  3. Interpersonal Effectiveness: learning assertive communication methods that enable an individual to engage with others in a way that maintains self-respect and simultaneously strengthens relationships
  4. Emotion Regulation: explores strategies that aid in changing unwanted emotions, by way of managing and/ or shifting the intense emotions that may be causing problems in one’s life

In DBT skills group session the clinician running the session will follow the lessons provided in the DBT curriculum, teach the skills and facilitate activities to allow the participants to practice using the DBT skills learned. After each DBT skills group session the clinician will assign homework to help practice and reinforce the information taught during the session. It is also important to note that the DBT skills extend beyond the individuals in treatment. In fact, an integral part of DBT is the assumption that effective treatment places equal emphasis on the behavior and experience of the mental health clinicians working with the individuals in treatment as it does on the experience and behaviors of the individuals in treatment. Hence, it is common practice for mental health providers offering DBT to integrate and regularly practice the DBT skills into their daily lives. 

Duration

The full DBT skills curriculum is intended to take twenty-four weeks long to complete. According to the Linehan Institute, this curriculum is often repeated to create a one-year long program. Shorter options that teach only a subset of the DBT skills have also been developed and are used in particular populations and settings. Although these timeframes are usually adhered to, the exact timeframe of a particular DBT program will depend on the specific needs of its participants, as the program may conclude in less time than the scheduled twenty-four weeks, or extend beyond, lasting longer than the twenty-four week period. 

Is DBT Covered By Insurance?

Dialectical Behavioral Therapy (DBT) is a combination of behavioral and cognitive therapies. The main goal of DBT is to transform negative thought patterns and destructive behaviors into positive outcomes. Although DBT was originally developed to treat individuals diagnosed with borderline personality disorder (BPD), it is now often used to treat individuals with suicidal ideations and/ or other self-destructive behaviors as well as other mental health conditions such as depression, post-traumatic stress disorder (PTSD), substance use disorder (SUD), and more. Additionally, it is highly common to integrate DBT into a treatment plan for an individual struggling with an eating disorder. Research has found that DBT has been shown to help with emotional regulation, building self-management skills, reducing anxiety, lowering stress and learning to effectively control destructive eating behaviors.  

How DBT Works

DBT treatment is generally a combination of individual therapy sessions and DBT skills group sessions. An individual will engage in one-on-one psychotherapeutic sessions with a trained therapist to address all the individual’s nuanced mental health needs, as well as help to encourage the individual to remain motivated to address obstacles that arise throughout the course of treatment, and apply the DBT skills learned in group sessions to his or her daily life. The DBT skills group sessions provide a forum and an emotionally safe environment for participants to learn and practice the DBT skills with other individuals going through the same experience. In the DBT skills group sessions a trained therapist introduces and teaches the DBT skills to the participants as well as facilitates relevant therapeutic exercises. Group members are assigned homework (i.e. practicing mindfulness exercises) to reinforce the lessons from the previous DBT skills session. Each DBT group skills session usually lasts about two hours, and the DBT skills group meetings are generally held once a week for about six months. 

The needs of the group members can increase or decrease the duration, greater or shorter than six months, of the DBT group skills sessions. Additionally, the format can change, as it will be tailored to the unique needs of the individual in treatment. For example, depending on the individual, some may benefit from the one-on-one therapy sessions without attending the weekly DBT skills group sessions, while others may benefit from participating in the weekly DBT skills group sessions without attending a regularly scheduled one-on-one therapy session. 

A fundamental component of DBT is the assumption that effective treatment, which includes the group skills training sessions, must place equal focus on the behavior and experience of the mental health provider working with the individual in treatment as it does to the behaviors and experiences of the individual in treatment. Hence, most mental health clinicians that offer DBT often practice the skills themselves. This helps the mental health clinician providing DBT reinforce his or her knowledge of basic behavior techniques as well as remain current with all DBT treatment strategies.

Insurance Coverage

At one point in time, the need for mental health treatment was stigmatized and health insurance companies did not prioritize this component of healthcare coverage. Fortunately, this has shifted as many mental health ailments are recognized as potentially equally debilitating as other physical health ailments (i.e. diabetes, physical disabilities…etc.) and are included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). While the details of mental health coverage will vary and the out-of-pocket responsibility will depend on the specific type of health insurance coverage, all health insurance companies are required to provide partial or full coverage for mental health treatment, including DBT carried out by a registered, certified mental health clinician. 

It is important to note that in America, there are a plethora of different types of healthcare insurance coverage options, including the array of health insurance companies and the variety of tiered health insurance coverage plans offered by each company. The health insurance premiums can range from $30 a month to over $1,900 a month depending on the insurance company selected and type of plan selected. Some plans will offer coverage only for services rendered by in-network providers, while others may offer full or partial coverage for services provided by out-of-network providers. The out-of-pocket responsibility will be wholly dependent upon one’s elected health insurance plan. In order to avoid any surprise healthcare bills it is essential to fully understand the intricacies of one’s health insurance plan. Make sure to call customer support on the backside of the health insurance card and inquire about coverage, out-of-pocket responsibility and/ or the need for any referrals and/or preauthorization requirements.