Dialectical behavioural therapy is a kind of talking therapy that was initially developed for adults with borderline personality disorder and emotional dysregulation. The name “dialectical” comes from a treatment philosophy that recognises how contradictory beliefs, feelings, and processes can simultaneously exist within a person. For example, DBT centres around the dual aims of radically accepting emotions and experiences while embracing positive change.
More recently, DBT has been adapted to treat adolescents (DBT-a) with a wide range of mental health symptoms and disorders, including non-suicidal self-injury (NSSI), suicidal behaviours, oppositional defiant disorder, binge eating disorder, and bipolar disorder.
Treating Self-Harming Behaviours with Dialectical Behavioural Therapy
Self-harming behaviours like NSSI are especially common among young people. Self-harm is usually a way for young people to manage very difficult or painful feelings. They may find that it distracts them from their emotional pain, grounds them, or offers some sense of control. However, self-harm only brings temporary relief, and their emotions soon resurface.
DBT-a focuses on coping with intense and difficult emotions, finding ways to reduce distress and improve self-worth. This might involve learning other coping mechanisms to manage intense emotions, or radically accepting feelings to make their experiences more tolerable. These skills can help young people reduce self-harming behaviours.
What Does Dialectical Behavioural Therapy Involve?
People living with trauma, intense emotions, and other kinds of psychological distress often experience contradictions and polarities. They may switch between the experience of overwhelming emotional pain and the invalidation of this same pain. Or they may engage in impulsive, self-harming behaviours to try to avoid confronting painful emotions.
These oscillations can cause additional distress, making it difficult to form a stable and coherent sense of self or perception of the world around them. One of the core aims of DBT is to help young people see that there is truth in each side of the polarity, creating a synthesis that holds and accepts parts of each perspective.
Dialectical behavioural therapy usually involves both individual therapy sessions and group skills training. Individual therapy sessions guide and support the person’s recovery journey, focusing on treatment planning, progress towards specific goals, motivation, and handling crises.
DBT group skills sessions teach the strategies and skills that support individuals to stay safe, improve their well-being, and build a better quality of life. Skill sessions centre around four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
Mindfulness Skills
Mindfulness skills are central to dialectical behavioural therapy and interwoven throughout the other skills. Mindfulness skills teach us to observe and participate in the present moment, without judging our thoughts, feelings, and experiences. They also help us to focus on one thing at a time and understand the course we should take to reach our goals.
Distress Tolerance
Distress tolerance teaches strategies for managing emotional pain, psychological distress, and crises without using harmful coping mechanisms. These skills include distraction, self-soothing, impulse control, and radical acceptance.
Emotional Regulation
Emotional regulation teaches skills for identifying, describing, and altering emotions. This might involve consciously acting in a way that contradicts the urges of an emotion to lessen its strength or duration. Or it might mean finding ways to experience more positive emotions.
Interpersonal Effectiveness
Interpersonal effectiveness training focuses on building stable, supportive, and fulfilling relationships with others while maintaining self-love and self-respect.
How Is DBT Adapted for Adolescents?
DBT for adolescents follows the same core principles and practices as DBT for adults. However, it involves some adaptations that make it more suitable for young people’s developmental stage, reflecting both biological differences and changing social roles.
Multi-Family Skills Training Groups
Multi-family skills sessions help families establish dynamics and relationships which support a young person’s recovery. In group sessions alongside other families, parents learn the same language that a young person encounters in therapy, helping them understand their child’s recovery process. They also share parenting skills and other techniques, such as validating emotions and experiences.
Within family group skills sessions, young people and family members can rehearse skills they’ve learned and begin to create new family dynamics.
Family Therapy Sessions
In DBT for adolescents, family therapy sessions – involving a single family rather than many – are offered on an ad-hoc basis. Therapists may arrange family therapy sessions when conflict or harmful family dynamics are a central theme in a young person’s life, or if the family is experiencing a crisis. They may also provide sessions if they think that a family could benefit from spending more time on a certain set of skills that may not have been adequately covered in multi-therapy sessions.
The goals of family therapy sessions may include:
- Supporting parents to understand a young person’s emotional experiences
- Addressing parents’ own ability to manage their emotions
- Improving communication within the family
- Learning how to manage crises
Addressing Family Dynamics
DBT for adolescents emphasises the role of the family system in shaping a young person’s emotions, behaviours, and recovery. It supports families to reorganise and create balanced dynamics that are neither enabling nor authoritarian; neither normalising nor pathologising.
Often, families and young people switch between these two extremes, causing distress and instability. DBT-a supports families to find a middle way: a balanced synthesis of two polarities.
Treatment Length
DBT for adolescents typically lasts for sixteen weeks, while DBT for adults involves a year of sessions. Adolescents experiencing suicidality or self-harming behaviours often only attend a limited number of therapy sessions, so they may be more likely to complete a shorter treatment course. Shorter treatment durations may also be more financially accessible to young people.
Adolescents who require or want to continue treatment may take part in additional therapy at the end of the treatment course, known as the ‘graduate group’. The graduate group is a sixteen-week course that aims to reinforce DBT skills and apply them to wider contexts. It focuses on peer-to-peer learning, rather than reliance on the therapist, creating a sense of self-mastery and autonomy.
‘Walking the Middle Path’
DBT-a includes a fifth module, ‘Walking the Middle Path’, in addition to the four original DBT modules. The module focuses on:
- Validation of the self and others
- Shaping behaviours through the family system
- Finding the balance between different family dynamics
Adapting Language and Form
Finally, the language of DBT sessions and handouts is adapted to meet adolescents’ needs. This includes streamlining language, simplifying terminology, and avoiding visual overstimulation. It also involves adapting the examples used to teach each skill to resonate with adolescents’ experiences.
How Effective Is DBT-a for Adolescents Experiencing Self-Harm?
A meta-review of DBT for adolescents found that DBT-A was a valuable treatment for both self-harm and suicidal ideation. It was also more effective than other interventions.
Research has also found that emotional regulation mediated the association between DBT and self-harm. This suggests that DBT, at least in part, works by supporting adolescents to understand, accept, and modulate their emotions.
Seeking Help for Self-Harm
Self-harm is always a sign of serious psychological distress. Any incident of self-harm should be taken seriously, regardless of the physical damage caused. If parents become aware that a child has self-harmed or is self-harming, they should seek professional support immediately.
It’s important to never minimise the experience of a young person self-harming, as this can cause emotions and behaviours to escalate. It’s also important to:
- Let a young person know you are there to support them
- Listen to what they have to say and validate their pain
- Reassure them
- Stay open-minded and nonjudgmental
The Wave Clinic: Specialists in Child and Adolescent Psychiatry
The Wave Clinic offers specialist mental health support for children, adolescents, young adults, and families. Our programs are trauma-focused, emphasising the role that past and present experiences play in shaping young people’s thoughts, feelings, and behaviours.
We place the family at the centre of our programs, acknowledging the importance of the family system in a young person’s recovery.
For young people who self-harm, we offer DBT-a alongside a selection of evidence-based modules. We offer parenting and family intensive services that aim to re-organise family systems and bring parents back into parenting roles.
If you’re interested in any of our programs, get in touch today.
