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Dialectical behavior therapy (DBT) is an evidence-based psychotherapy treatment that was originally developed by Marsha Linehan, in the late 1980s, to help treat individuals diagnosed with borderline personality disorder (BPD). Research has shown that since its inception it has become an effective form of treatment for individuals with other mental health disorders. The DBT approach is now frequently implemented in treatment plans for individuals (both adolescents and adults) struggling with any single or combination of the following ailments, as listed by the Child Mind Institute: 

• Drugs and/ or alcohol abuse 
• Substance use disorder
• Anxiety/ generalized anxiety disorder (GAD)
• Impulsive and/ or disruptive behaviors
• Attention-deficit/ hyperactivity disorder (ADHD)
• Frequent mood swings
• Bipolar disorder
• Self-injuring behaviors
• Depression/ major depressive disorder (including treatment-resistant major depression and/ or chronic depression)
• Suicidal behaviors
• Poor coping skills
• Anger outbursts
• Eating disorder behaviors/ bulimia/ binge-eating disorder/ anorexia 
• Family and/ or peer conflict
• Post-traumatic stress disorder (PTSD)

DBT is based on the cognitive behavioral therapy (CBT) approach that relies on talk therapy and emphasizes the psychosocial aspects of treatment. Dialectical behavior therapy helps teach individuals healthy coping mechanisms and useful techniques for managing stress, regulating emotions, and improving relationships with others. 

Therapeutic Settings

Dialectical behavior therapy is conducted three therapeutic settings, which include individual therapy sessions, group skills therapy sessions, and coaching. Individual therapy sessions provide a client and his or her clinician the opportunity to co-create behavior plans that incorporate long and short-term goals as well as delve deeper into and process the client’s life journey while also learning skills to improve self-worth, establish self-compassion, acceptance and a positive self-identity. These sessions are empowering in teaching a client skills, many of which will serve them for the rest of their lives. Group therapy sessions provide clients to learn DBT skills and a safe environment to practice implementing skills learned in both group and individual therapy sessions. The structure of group therapy sessions enable an individual to learn important behavioral skills from peers as well as encourage new, healthy ways of interacting with others. Coaching is a component of DBT that provides the client access to his or her clinician between individual and group therapy sessions. An individual can call his or her clinician to receive support and guidance for coping with challenging in-the-moment situations.

DBT Skills Training

DBT utilizes four main strategies for teaching individuals skills that help with effectively changing their behaviors. They include the following: 

1. Mindfulness: the practice of remaining present and fully in the moment at any given time
2. Distress Tolerance: learning to tolerate pain in challenging situations, without changing it or escalating it
3. Interpersonal Effectiveness: increasing one’s self-awareness through learning to effectively advocate for one’s own wants and/ or needs by saying no and/ or expressing one’s desires while maintaining self-respect and without feeling that relationships will be compromised 
4. Emotion Regulation: learning how to shift and/ or change unwanted emotions

DBT helps individuals transform negative thoughts and behaviors into an understanding of one’s life journey and ultimately helps to establish mindfulness and self-compassions, which are beneficial and can be useful throughout one’s entire lifetime. 

DBT Adolescent Skills Groups

Adolescents, typically between the ages of twelve to nineteen years old, must attend group therapy sessions as a component of DBT.  Adolescent DBT group therapy generally extends to parents and/ or caregivers. By attending group sessions together, the adolescent and his or her support system can learn DBT skills together. In DBT group skills sessions, adolescents learn and practice implementing DBT skills used to help communication, regulate emotions, improve relationships, enhance moods, and practice effective problem solving skills. These group sessions are helpful for parents’ and/ or caregivers as the sessions allows them to learn effective methods of communication and gain an understanding for how to better empower their adolescent to employ the DBT skills to deal with problems and navigate challenges. 

DBT Adult Skills Groups

Much like the adolescent DBT skill groups, adult skills groups are an integral component of one’s DBT treatment. Adult skills groups are comprised of other individuals experiencing similar concerns. The skills addressed in the group sessions reflect the four main pillars of DBT (mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation). The associated skills are also worked on in a group setting. This provides a client the opportunity to implement the skills, tools, and coping mechanisms learned with peers in a safe and controlled environment. The work that occurs during the skills groups continues, as homework that corresponds to the DBT skills taught or visited during each DBT group session are regularly assigned. 

Adolescence is an incredibly challenging time in one’s live. There are rapid and exponential psychological, physical, emotional and developmental maturation processes that occur simultaneously as a result adolescence. Hormones are surging through teenagers’ bodies and navigating how to regulate the emotional and physical impact of them is difficult. Often teenagers employ a trial and error method for coping as a means to manage the intense changes they are experiencing. Every teen is different and will experience and process the stressors related to adolescence distinctly.

Self Harm In Teens

Adolescents that inflict self-harm and/ or self-mutilation can do so in a variety of different ways. This can occur on any area of one’s body, but it is most frequently seen on the arms, legs, and/ or front of the torso. The Mayo Clinic provides a comprehensive list of reported self-harming methods, some of which include the following examples: 

• Scratching
• Carving and/ or branding one’s skin
• Hitting oneself
• Burning
• Ingesting poison
• Cutting
• Inserting foreign objects under the skin and/ or into one’s body
• Head banging
• Pulling hair out
• Getting excessive body piercings
• Picking scabs to prevent wounds from healing
• Jumping in front of vehicles and/ or from high places
• Overdosing on drugs and/ or medication

It is normal and should be expected that the majority of teenagers are likely to experience an array of pain in during their teenage years. However, it is abnormal for a teenager to purposefully engage in self-mutilation and/ or self-harm and must obtain professional help immediately. 

Warning Signs

Teenagers are notorious for exhibiting moody behavior and remaining exceedingly private. There a plethora of potential reasons for the impetus behind why a teenager acts the way he or she does, but the reality is those reasons are rarely, if not ever, revealed to a parent and/ or caregiver. There are specific warning signs for which to be on the lookout regarding self-harming behaviors in teens. Examples of these warning signs can include, but are not limited to the following:

• Missing patches of hair (from head, eyebrows and/ or eyelashes)
• Spending time with people that harm themselves
• Only wearing long sleeved clothes, regardless of the outside temperature
• The presence of cuts, bruises, scratches, burns, and/ or carvings on one’s body
• Self-isolation
• Noticing sharp objects hidden in his or her belongings

Many warning signs that are indicative of a teen inflicting self-harming behaviors are similar to typical behaviors exhibited by any teenager. It is important to note, that not all adolescents that present with any combination of the above examples is undoubtedly causing self-harm. However, if concern arises it is best to seek the guidance of a qualified mental health professional as soon as possible to assure the safety of the teenager. 

Treatment Options

There is an array of treatment options available for a teen struggling with self-harm and/ or self-mutilation. The first step is to have a calm conversation with the teenager expressing concern and offering support. The next step is to set up an appointment for the teenager to get evaluated by a mental health professional. This will illuminate the presence of any underlying mental health issues that may be driving the teen to engage in self-harming behaviors. The mental health evaluator will also be able to provide guidance as to subsequent steps to help the teen obtain the needed support to stop the self-destructive behavior. 

It is highly common for some form of formalized treatment to be recommended by the evaluating mental health professional. A teen may benefit from individualized therapy as a means to treat his or her self-mutilating and/ or self-harming behaviors. There are formalized outpatient mental health programs that require the teen to participate in the treatment program for a certain number of hours, daily. Depending on the severity of the situation, there are also acute inpatient mental health treatment programs that offer twenty-four-hour care and support throughout the duration of the program. In severe cases, hospitalization may be necessary. 

The treatment approaches vary, as they are contingent upon the specific needs of the teenager. A customized treatment plan is developed to accommodate the nuanced needs of the teenager. Generally the treatment protocol for teens that engage in self-harm will include some combination of different psychotherapy approaches. Certain psychotherapy modalities that are commonly integrated into treatment plans for teens that self-harm include cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), psychodynamic psychotherapy, mindfulness-based therapy, creative arts therapies, and/ or family therapy. Treatment plans may also include medication. Some medications can be helpful in decreasing uncomfortable symptoms associated with other underlying mental health issues, which in turn can reduce the urge to self-harm. 

There are a variety of treatment options that can include an array of different therapeutic methods that are available for an individual seeking treatment for an eating disorder. The principals of dialectical behavior therapy (DBT) are based on those of cognitive behavioral therapy (CBT). The CBT method works to help an individual learn how his or her feelings, thoughts, and behaviors influence each other. DBT is more keenly focused on the social and emotional aspects, as it helps individuals learn to cope with extreme, unstable and/ or harmful behaviors. Dialectical behavior therapy has evolved into an evidence based psychotherapy approach that is utilized as treatment for an assortment of mental health conditions. 

Eating Disorders

Eating disorders are serious mental illnesses that are characterized by persistent, damaging eating behaviors. They can have grave affects on one’s emotions, health, and capacity to adequately function in important areas of one’s life. There are a number of different manifestations of eating disorders. The various types are listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) under the Disorder Class: Feeding and Eating Disorders. The three most common eating disorders are anorexia nervosa, bulimia nervosa and binge-eating disorder. If left untreated, eating disorders can result in severe short and long-term consequences. While eating disorders are life-long conditions, with treatment, ample support, and steadfast commitment, an individual can learn the tools and skills needed to go on to live a successful, meaningful, and healthy life. 

Dialectical Behavior Therapy

Psychologist Marsha Linehan developed dialectical behavior therapy in the late 1980s. It was initially developed as a means to help treat individuals with borderline personality disorder (BPD) and/ or with chronic suicidal ideations. As time has progressed it has become evident that DBT can be helpful in treating individuals with other mental health conditions and/ or mood disorders. Research has shown that DBT can be advantageous when integrated into one’s treatment plan for mental disorders such as depression, substance use disorder, post-traumatic stress disorder (PTSD), and eating disorders. 

DBT can benefit an individual diagnosed with an eating disorder by helping to foster self-management skills, lower stress, reduce anxiety, and learn to control destructive eating behaviors. The goals of DBT are to help a client learn to establish healthy coping mechanisms that can be applied to environments that would have otherwise provoked engaging in destructive eating behaviors and/ or patterns. It helps clients learn how to reduce emotional reactivity and improve their interactions with others. DBT promotes acceptance and teaches skills to enable an individual to live in the moment and cope with emotional triggers that may otherwise perpetuate eating disorder symptoms and behaviors. 

How Does It Work?

DBT includes a combination of individual therapy sessions, group therapy sessions as well as coaching support. Every individual is different and will require some form of customized treatment plan when it comes to eating disorders. Therefore, the individual therapy sessions are essential in creating a forum for the client to work on his or her own nuanced issues with one-on-one guidance from his or her clinician. Creating personalized behavioral plans and goals surrounding mindful eating are established in individual therapy sessions. These sessions are beneficial in empowering a client as they help to establish and nurture self-compassion, increase one’s sense of self-worth, and develop a positive self-image. 

Group therapy sessions enable a client to practice the skills learned in individual therapy sessions. They can offer a safe environment to connect with other individuals experiencing similar life challenges. Furthermore, they allow individuals in recovery to engage in healthy interpersonal connections, while simultaneously cultivating a support network. Individuals have an opportunity to share their experience as it relates to their personal recovery process as well as offer support and insights to others in the group. Group therapy sessions also teach individuals important self-management life skills while creating an opportunity for the individuals to implement these skills in a group setting (i.e. mindful eating in a group environment). 

While group therapy sessions and individual therapy sessions can provide enormous support, it is not uncommon for a client to experience moments of distress between sessions. During those moments between individual therapy sessions and group therapy sessions, DBT offers coaching guidance. Clients can request clarification for and discuss how to implement certain management skills and/ or self-soothing techniques. If a client is struggling and/ or is in crisis he or she can reach out to and speak with his or her clinician for support over the phone, at any time. The coaching component of DBT is extremely helpful for an individual, as he or she knows that support is available during times of need.

Dialectical behavior therapy, DBT, is a type of therapeutic treatment that falls under the larger umbrella of CBT (cognitive behavioral therapy). DBT was developed in the late 1980s by Marsha Linehan, Ph.D., as a means to specifically treat individuals with borderline personality disorder (BPD). As time has progressed, it has proven to be an effective method in the treatment of individuals that suffer from other types of mental health disorders. While DBT utilizes a cognitive behavioral approach, it predominantly emphasizes the psychosocial aspects of treatment. The theory behind the DBT approach takes into consideration the notion that some individuals are prone to react in a more intense manner when it comes to certain emotional situations. The biological response manifests as an exponential increase in one’s arousal level (different from an average person’s), elevating one’s emotional stimulation, which in turn takes an individual a longer duration of time for the individual to return to his or her baseline arousal level. In order to adequately regulate one’s emotions an individual with borderline personality disorder must integrate specialized coping techniques. 

Borderline Personality Disorder

Borderline personality disorder is a mental health disorder that impacts the way an individual thinks about him or herself and others. As is described by the National Institute of Mental Health, it is characterized by an ongoing pattern of varying moods, behaviors, and self-image. The precise cause for developing borderline personality disorder remains unknown. There are, however, certain risk factors that research has suggested that may increase one’s susceptibility. Contributing risk factors include: genetics, one’s brain structure, family history, as well as environmental, social, and cultural factors. The symptoms of borderline personality disorder typically result in impulsive actions and relationship problems. The Mayo Clinic provides examples of signs and symptoms that are commonly exhibited in individuals with borderline personality disorder. They include the following:

• Engaging in risky and/ or impulsive behaviors (i.e. reckless driving, excessive gambling, binge eating, substance abuse, unsafe sex…etc.)
• Intense fear of abandonment
• Suicidal ideations
• Self-injury
• Severe mood swings (i.e. elation, irritability, shame, anxiety…etc.)
• Pattern of unstable relationships
• Irrational displays of anger
• Distorted self image
• Feelings of emptiness
• Stress related paranoia

Every person is different and an individual with borderline personality disorder has the propensity to experience any combination of the above symptoms. Borderline personality disorder is notorious for being an incredibly challenging mental health disorder to both diagnose and treat. The article, Why Psychiatrists are Reluctant to Diagnose Borderline Personality Disorder, pinpoint several challenges psychiatrist’s face when diagnosing borderline personality disorder. Borderline personality disorder is a mental health disorder that is treated by teaching an individual how to manage his or her symptoms. Hence, there is no known treatment for borderline personality disorder that fully eliminates or cures an individual from its diagnosis. 

Dialectical Behavior Therapy

Individuals who are diagnosed with borderline personality disorder tend to view things in extremes (i.e. all good or all bad). This can greatly impact the way one subsequently behaves which can make it challenging to function in one’s everyday life. The American Psychological Association assert that individuals who have undergone DBT as a component of treatment for borderline personality disorder have displayed notable improvements in the following areas:

• Shorter hospitalizations
• Reduced anger
• Less frequent and/ or less severe suicidal ideations
• Improved social functioning
• More likely to remain in treatment

It is highly common for individuals with borderline personality disorder to be unable to adequately cope with the sudden experience of surging of emotions, which is a typical symptom of the disorder. DBT helps teach clients learn and integrate coping mechanisms to help with changing unhealthy behaviors. DBT is made up of four modules. The modules are intended to shed light on situations where the objective is to change something (i.e. asking someone to do something) or to resist changes someone else is attempting to make (i.e. saying no). The four modules of dialectical behavior therapy treatment are:

1. Mindfulness: active practice of being fully aware and present in the moment
2. Interpersonal effectiveness: learning to advocate for one’s wants as well as say “no” while maintaining self-respect and outside relationships
3. Distress tolerance: learning to tolerate (not change) pain in challenging situations
4. Emotional regulation: learning to decrease vulnerability to painful emotions and change unwanted emotions

It is important to note that many individuals with borderline personality disorder have substantial interpersonal skill, but they are unable to properly apply their skills within the appropriate context. Obtaining treatment is essential in providing an individual with borderline personality disorder the needed tools to manage his or her disorder.