Dialectical Behavior

Therapy with Suicidal Adolescents by Alec Miller,

PsyD, Jill Rathus, PhD, Marsha Linehan, PhD

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Dialectical Behavior Therapy with Suicidal Adolescents by Alec

Miller, PsyD, Jill Rathus, PhD, & Marsha Linehan, PhD

There are many actions that may be considered to fall under the general category of suicidal behaviors.

Supposedly, these distinctions are made based on whether there is a strong intention to end one’s own

life. However, measuring this would be difficult.

Completed suicide is a successful attempt at killing oneself. A suicide attempt is an action wherein the

goal is to end one’s life. Non-suicidal injurious behaviors (NSIB) may mean engaging in the same

behaviors as in suicide attempts, but the intent is to escape from emotions and signal distress rather than

to kill oneself. On the other hand, suicidal ideation means desiring death and thinking about committing

suicide. These different suicidal behaviors can appear simultaneously or one at a time at different points

of a person’s life.

The developmental goal of adolescence is to individuate—create a solid sense of self by moving away

from the influence of parental figures and building one’s own identity. Studies show that this is the life

stage where suicide attempts are most prevalent. The occurrence of NSIB appears to be increasing among

people in this age group as well. This is a serious public health issue that affects thousands of teenagers

worldwide.

Risk factors for adolescent suicide

Studies show that adolescents are more likely to engage in suicidal behavior when they have a certain

background combined with a highly stressful life event. The background influences are called “distal risk

factors” while precipitating events are called “proximal risk factors”.

Strong risk factors include prior suicidal behavior, existence of mental and personality disorders, chronic

depression and anxiety, reckless and troublesome behavior, substance abuse, and a history of family

discord. There are also differences between males (higher rates of complete suicide) and females (higher

rates of suicidal ideation and attempts). Studies show it is two to six times more likely that members of

the LGBTQIA+ community attempt suicide than heterosexuals. Ethnicity seems to play a role as well—in

the United States, suicide is most prevalent among Native Americans, followed by Caucasians, African

Americans, then Asians and those from the Pacific Islands.

Proximal risk factors are stressful events that are likely to trigger suicidal behavior when risk factors are

present. These include problems within important relationships (usually between younger adolescents and

their parents, and older adolescents and their romantic partners), disciplinary issues, public disgrace,

sexual and physical abuse, difficulty in academics, and occurrence of a disability or illness (particularly

HIV-AIDS). Exposure to stories about suicide, either fictional or in reality, can ramp up the number of

attempts among the adolescents who hear about it—particularly those who bear similarities to the

character or person portrayed in the story. Increased accessibility to instruments for suicide also increases

the probability of attempts. For example, lax gun laws in the United States could account for the higher

prevalence of gun suicides as compared to hanging, which is the most common method worldwide.

Bipolar disorder and suicidal behaviors in adolescents

Personality disorders are rarely diagnosed during adolescence because of the commonly held belief that

personality is still developing at this stage. However, studies show that bipolar disorder (BPD) can be

identified in teenagers—with treatment, some patients “outgrow” the disorder, but for others, it is a

permanent condition.

Bipolar disorder is associated with a high incidence of dysfunctional behaviors, including substance

abuse, eating disorders, difficulty in relating with others, and suicidal behaviors. Studies show that

adolescents diagnosed with BPD have the same issues as their adult counterparts.

The precipitating factors of bipolar disorder coincide remarkably with suicidal behaviors, such that DBT,

a treatment originally developed to treat suicidal individuals, is now more associated to bipolar disorder.

Treating suicidal behaviors in adolescents

There are two schools of thought when it comes to treating suicidal behaviors: The first is to treat it as a

symptom of a mental or personality disorder. The thinking is that by treating the disorder, the incidence of

suicidal behavior will also disappear. The second school of thought focuses on treating the suicidal

behavior separately from whatever disorder is present. The interventions are geared towards lowering the

occurrence of self-harm. However, there are very few studies comparing the effects of various treatments

on adolescent suicidal behavior.

The use of pharmacotherapy has focused on depressive disorders. There is no conclusive evidence

showing that antidepressants can lower the incidence of suicidal behaviors. In fact, the US FDA requires

that all antidepressant drugs be labeled with warnings that consumption may lead to increased suicidal

tendencies. As such, behavioral therapies have gained popularity above over-the-counter drugs in

lowering the incidence of self-harm and suicide.

There have been many treatments developed to reduce the risk of patients engaging in suicidal behaviors,

although there are a limited number of clinical trials to test their efficacy. There are even fewer studies

that delve on using these techniques on adolescents. Treatment methods include treatment-as-usual

provided by in-patient clinics, variations of cognitive behavioral therapy, family- and group-based

therapy, psychodynamics, among others.

Based on these studies, it appears that treating suicidal behaviors separately from mental disorders is more

effective in avoiding complete suicide, attempts and NSIB. Interventions are best done in an outpatient

setting rather than being confined in a clinic or hospital. Among these, dialectical behavioral therapy

(DBT) is the only method shown to effectively reduce the incidence and the medical risks of suicidal

behavior in more than one clinical trial.

Suicidal behaviors within the dialectical behavior therapy framework

Within the DBT framework, suicidal behaviors are seen as a dysfunctional way of coping with problems.

Individuals who engage in these acts may not have the skills that allow them to regulate their emotions,

tolerate stress and seek help from others. They may also experience conditions that impair their ability to

solve problems in a healthy and constructive way. As a result, they turn to suicidal behaviors as a means

of escaping difficulties.

The biosocial theory is key to understanding suicidal behaviors and bipolar disorder. There is a biological

component—usually a genetic predisposition, early trauma to the nervous system, or prenatal

conditions—that physiologically impairs an individual’s ability to regulate emotions. Equally important is

the social component, also called “invalidating environments” within the family, neighborhood or school

setting wherein an individual’s personal experience is ignored, minimized, criticized or punished. Note

that not all invalidating environments are born out of neglect or abuse—even those who want the best for

their children or wards may not be equipped with the skills needed to manage emotional impairment.

Viewing suicidal behaviors in this way promotes compassion towards patients and their families, creating

a more positive, nonjudgmental environment for therapists and staff.

DBT aims to remove the patterns of thinking and behavior that precede suicidal behaviors, and introduce

healthier and more effective ways of managing problems. It helps those with suicidal tendencies to apply

these techniques appropriately when dealing with difficult situations. It is a combination of four modes:

individual therapy, group skills training, therapist consultation and telephone consultation in between

sessions. The different modes offer flexibility to cover several complex concepts within a single session.

Because it involves the family or support group of the patient, DBT addresses the social and

environmental factors outside the clinic. It also equips the patient’s family members with the skills needed

to help them deal with suicidal behaviors.

DBT also has the advantage of targeting noncompliance and aversion to therapy that frequently occurs in

suicidal patients. This treatment aims to enhance the motivation of a patient to change. In addition, studies

show DBT leads to reduced visits to psychiatric wards and emergency rooms—testament to its effectivity

and cost-effectiveness.

Key principles in dialectical behavior therapy

The methods and techniques used in DBT centers around the understanding that disorders are systemic

dysfunctions—this means that the condition is a departure from normal functioning. Disorders are

manifested in extreme behaviors or thought patterns that are essentially outliers on the spectrum. The term

“dialectical” refers to creating a healthy balance that can be summarized in the opposing ideas of

acceptance and change.

The main players in DBT are a community of clients and a community of therapists. The former refers to

the patient and his/her family, friends or support group. The latter refers to the primary therapist and a

support team of other therapists.

Stages of DBT

DBT starts with the pretreatment stage. The goal is to inform the client what to expect, clarify any

reservations and gain commitment about pursuing the therapy. Behaviors that are target for change are

identified and agreed upon by the client and the therapist. Diagnostic exams, personal history interviews

and behavioral analysis are included in this stage.

The first stage of DBT is geared towards individuals with the most severe problems. A case is considered

severe if the disorder prevents the client from staying in school or keeping a job, maintaining important

relationships, or when a client poses an immediate threat to themselves or others. The goals, in order of

importance, are to decrease self-harming behaviors, decrease behaviors that obstruct or interfere with

commitment to therapy, decrease behaviors that negatively affect quality of life, and increase behavioral

skills such as tolerating stress, emotional regulation and mindfulness.

The following stages of DBT more closely resemble standard cognitive behavioral treatment techniques.

Stage 2 targets post-traumatic stress, Stage 3 focuses on building self-respect and setting goals, and Stage

4 aims to address the feeling of incompleteness and help the client find happiness and a sense of freedom.

Techniques used in DBT

1) Dialectical strategies. These focus on shifting the client’s perspective from “either-or” (extremes) to

“both-and” (balance). This includes techniques such as entering the paradox (presenting the client with

contradictions and asking them to explain), use of metaphors (telling stories, fables or parables that a

client can understand, then applying the lesson to something the client finds difficulty comprehending),

playing devil’s advocate (exaggerating a dysfunctional thought a client makes and allowing them to argue

against it), extending (taking seriously a statement that the client did not intend to be taken seriously), or

seeing the silver lining (helping them see challenges as opportunities).

2) Validation strategies. These focus on recognizing, accepting and giving importance to another

individual’s personal experience—emotions, thoughts and responses. The therapist must show an active

interest in what the client has to share and be able to understand where he/she is coming from. A deeper

level of validation occurs when the therapist is able to identify feelings and underlying meanings that the

client may not be aware of, based on what they have shared.

Behavior is then validated—justification of the behavior is not about whether it is right or wrong, but

rather, whether one can understand why the individual reacted that way. Instead of judgment, the focus is

to arrive at what caused the behavior. Once this has been understood, then the therapist may help point

out how appropriate the response was, and show how it was dysfunctional, if applicable. Cheerleading

strategies that focus on acknowledging the patient’s effort and showing belief in their ability to get

through challenges are used in this stage.

3) Problem-solving strategies. Problem solving starts with behavioral analysis. This is usually done by

reviewing what happened during the week using diary cards. Diary cards is when Problematic behaviors

are identified, and the therapist asks questions in order to determine what caused it. Keep in mind that

behavior is usually a way to solve a problem—for example, a person may choose to drink to forget about

an overwhelming situation.

Once the problem is identified (i.e. coping with a difficult situation), alternative solutions are presented.

Instead of drinking, perhaps the individual could talk to a friend about it, or calm down by taking a walk,

or make a pros-and-cons list to better understand the choices he/she has. The therapist walks the client

through different management strategies, and together they can choose which is most effective. Skills

training, contingency procedures, repetitive stimulus exposure and cognitive modification are used in this

stage.

Therapy communication styles employed in DBT

DBT promotes a balance between two seemingly opposite types of communication styles. Reciprocal

communication is designed to show vulnerability of the therapist to the client. This is done by being

warm, open and sincere about how the client’s actions affect the therapist. It involves self-disclosure and

creating contingency management, either reinforcing or punishing the client’s behaviors. A therapist

employing this style on a difficult client may say “I want so badly to help you, but it seems you don’t

want to follow what I believe is best for you.”

Irreverent communication is used to jolt the client. It is delivered in straightforward, deadpan manner,

occasionally with humor and candor. Responding to a threat of quitting therapy, a therapist may reply

“Do you need a referral?”. Adolescents who are used to having adults react to them in a particular way are

thrown off by this communication style, and may not act as tempered or removed as they usually would

with authority figures.

A balance of these two forms is integral, as just using one does not constitute DBT. The therapist must

learn which to employ at particular moments.

Strategies for environment intervention

There are times when the client’s environment may hinder the treatment process. In these cases, there are

three strategies that therapists can employ to continue DBT.

Consultation-to-patient strategy is most commonly used. The therapist is a consultant to the client.

Decisions about the treatment, particularly changes in the social environment, are made with the

knowledge and agreement of the client. The therapist deals with the client on a one-on-one basis, and has

no communication with individuals in the client’s network unless in the presence of the client themselves.

This allows the client to take charge of his/her journey to healing.

Consultation team meetings are essentially a group of therapists who administer DBT to the therapist

treating the client. They serve both as a support group to keep the therapist on-board with the client, and

as a way to balance the therapist’s power dynamics with the client.

Program structure of DBT

DBT is only effective if it can fulfill the following functions. For each function, there is an accompanying

mode of treatment. However, these modes can be changed depending on what is most effective.

To improve the client’s motivation to change, individual therapy sessions are conducted. These are

usually one-hour sessions held weekly. They consist of examining the client’s DBT-template diary cards

and going through the problematic behaviors encountered. The primary therapist in the DBT therapy team

conducts this.

To enhance the client’s capabilities, they join a group skills training. This is held on a weekly basis

outside of the individual therapy. There are five modules: mindfulness, emotional regulation, social

effectiveness, stress management and dialectical thinking and behavior. It is usually a different therapist

within the DBT team who conducts group skills training.

To make sure that the skills the clients learn are being applied at home, the primary therapist provides

consultation over the phone, individual therapy and family therapy. Regular telephone calls can allow the

therapist to help the client in between sessions—coaching them to use the skills on difficult situations, or,

if the problem is too complex to deal with at the moment, to calm the client down until the next meeting.

Homework assignments provided by the skills training therapist, combined with individual therapy with

the primary therapist may also be used towards the same function. Including family members in therapy

also ensures application of skills at home.

To help create an environment conducive to changing the client’s suicidal behavior, the DBT therapy

group can communicate with family and other important figures in the client’s life. Discussing DBT and

its aims is integral, as well as providing skills training. The goal is to help them create a validating

environment for the client, provide reinforcement for positive behaviors and create deterrents to

problematic behaviors outside the therapy environment.

To enhance the capabilities and motivations of the therapists, one- to two-hour consultation with the DBT

group is done on a weekly basis. It usually begins with a mindfulness exercise, followed by reading of

team agreements (agreement to be empathic to clients and their families, agreement to abide by dialectical

principles and balance out extreme opinions within the team, among others) then a review of the previous

week’s notes. The agenda is then set by the entire team, revolving around the hierarchy of DBT targets.

Then at least thirty minutes is used for further DBT training and practice.

Setting up a DBT program for adolescents

The first step is to define the client population. Decisions on setting limits on age range, gender, diagnosis

and other cultural factors must be made. It would be ideal to have a group with the same background and

going through the same problems as it makes self-disclosure and relating easier. However, this represents

a rare scenario. In reality, it is difficult to have a homogenous group of clients.

The DBT team should consist of two professional therapists at the minimum. They should have previous

experience in conducting DBT, dealing with teenagers and holding family therapy sessions. It would be

helpful to have professionals from other fields such as pharmacists, social workers, medical staff who can

provide supplemental health. All team members should be educated on the principles, techniques and

modes of DBT to ensure treatment is consistent.

The DBT standard is modified slightly to better fit the needs of adolescents. Including family members in

group skills training is not part of DBT for adults, but given that adolescents usually live and are

dependent on their families, this becomes an important consideration. Depending on the situation, skills

training with family members can be held partly with their children (3-4 times out of the total 16

sessions), and partly separate, or completely separate. Providing telephone consultation between sessions

for family members may also help, although care is taken to ensure that the adolescent’s trust in the

therapist is not marred by talking to their parent.

It is also common among DBT adolescent programs to keep the treatment schedule within 16-weeks.

Once completed, the clients join a graduate group that provides support even after the program.

The shortened program focuses on fewer skills than the standard DBT. These are the skills that are most

relevant to the adolescent age group: teaching validating behaviors, behavioral skills training (using

reinforcement to encourage good behaviors and punishment to reduce problematic behaviors), and

discussing key dialectical concepts within the parent-teenager relationship.

Dialectical dilemmas in adolescent relationships

In standard DBT, there are three dialectical concepts that must be balanced:

1) An individual diagnosed with BPD or who engages in suicidal behavior is emotionally vulnerable and

reacts quickly with strong emotions. The tendency is for them to invalidate themselves by feeling

ashamed of being so sensitive, convincing themselves they are overreacting, and oversimplifying

solutions.

To balance out being highly sensitive and reactive, the DBT therapist must help them tone down the

intensity of how they feel. They can do this by taking a step back from their emotions and engaging in

self-care techniques. To balance out the tendency to invalidate oneself, the therapist can help the client by

teaching them to identify and attend to their feelings, nonjudgmentally observing how they feel instead of

suppressing it, and use small reinforcing measures to help progress bit by bit towards their goals.

2) It is common to encounter clients in DBT who appear to depend on others to solve their problems. And

yet, they appear perfectly capable of resolving it on their own. This leads to clients being labeled as

manipulative. However, it is important to remember that a person suffering from BPD or suicidal

tendencies may be appear competent one moment, but completely unravel the next—they may just choose

not to show it.

The key to balancing this out is being able to determine what they need help with and asking for it from

the right people, and at the same time, identifying and expanding the type of situations where they can

fend for themselves. The therapist can help by pinpoint vulnerabilities and strengths of the client, and

building up capabilities where needed. Additionally, the therapist should help the client function properly

despite mood swings.

3) Clients with BPD or suicidal tendencies may at times create problem after problem, or attempt to avoid

all problems by closing down. To balance this out, it is important to improve rational decision making

skills and address behavior that exacerbates existing or creates new issues. Problem avoidance may seem

to work temporarily, but it results in inability to regulate emotions in the long run. Helping clients feel

and manage difficult emotions such that they do not result in impulsive avoidance behaviors is key to this

goal.

There are also three specific dialectical dilemmas that apply especially to adolescents and their parents in

DBT:

1) Parents must find a balance between being overly permissive and being overly strict. To do this would

mean adopting an authoritative parenting style—being clear about what constitutes mature, responsible

behavior and holding their children firmly to that standard, while still showing support, care and respect

for their kids.

It is integral that parents learn to communicate expectations and consequences with consistent

implementation. Equally important is rewarding positive behavior. The same principle should be applied

to how the client treats her/himself. They must learn to set realistic goals and reward themselves in small

and frequent ways as they move towards them. Impulsiveness is tempered by practicing delayed

gratification, weighing the pros and cons of possible responses and learning to tolerate difficult emotions.

2) For parents with BPD or suicidal adolescent children, it may be difficult to differentiate “normal”

teenage behavior with truly problematic behavior. This life stage is characterized by moodiness, the need

to individuate and relinquish their parental control, and changes in their body and thinking that can be

confusing and difficult to manage. However, children who have BPD or engage in suicidal behavior take

these to the extreme.

The same may happen to adolescents themselves—they don’t know if their actions are normal or caused

by their extreme sensitivity, but they also tend to downplay the seriousness of truly problematic

behaviors. It is important for parents to be educated about what constitutes normal behavior and

worrisome behavior from a psychological point of view—usually if the behavior results in harm to self or

others, dropping out of school, contracting STIs, or other life-disrupting events, it needs to be taken

seriously. This way, both parents and children know what is normal and what needs help.

3) Parents may find it hard to strike a balance between sheltering their kids too much and pushing them

out to the world too abruptly. The former hinders the adolescent’s individual growth and capacity-

building, while the latter fails to provide support for teenagers navigating an adult world.

For parents, this means allowing their children to figure things out on their own, while being there in case

they ask for help—building support groups between parents who are going through the same issues can

help. For adolescents, this means learning the difference between asking advice on how they could solve a

problem versus allowing another person to solve it for them completely. They also need skills training in

problem-solving, including thinking of pros and cons, and acting out after thinking instead of out of

impulse.

Assessment prior to starting DBT

It is important to assess whether an adolescent can be admitted to the DBT program. The first step is to

assess the degree to which the teenager engages in suicidal behaviors and ideation. This is a sensitive

topic, so the clinician would do well to establish a sense of rapport with the potential client. Therapists

can use self-report accounts of previous suicidal behaviors, standardized measures of intentionality to kill

oneself, and structured interviews. If there are stressful events or traumatic history, clinical evaluation of

the potential client as well as description of the abuse from multiple sources should be conducted.

Diagnostic evaluation of possible disorders should also be undertaken. Semi-structured interviews as well

as self-reports from both the adolescent, parents and other authority figures are important. There are

diagnostic tests specific to certain disorders—usually those meant for BPD and affective disorders are

used, given their correlation to suicidal behavior.

Self-report questionnaires, observer ratings and interviews conducted with the adolescent and his/her

family can be used to understand family history and situation that could contribute to existing disorders.

The next step would be to identify which behaviors to target. This involves behavioral chain analysis of

life-threatening and therapy-interfering behaviors—what function it fulfills, what causes it, and what

effects it has on the client.

The final step is to assess how feasible it is for the adolescent to undergo DBT. This not only includes

financial and logistical concerns, but commitment to participate for both the potential client and his/her

parents. It is at this stage that the initial plan for treatment is developed, which will be signed on by the

therapist and the client.

These are used for initial assessment, but regular use of these tests can help with treatment. However, care

should be taken not to burn out the participants with a battery of tests frequently. In addition, the DBT

team would benefit from an evaluation from involved parties after the treatment has been completed.

Building client commitment to DBT

The first step is to create rapport with the client and his/her family. This involves communicating with

them in an open, approachable manner while establishing credibility and commanding a level of respect.

Orientation starts with a review of the diagnostic results. The problem behaviors identified are

categorized into areas: confusion about the self, impulsivity, emotional unsteadiness, relationship-related

problems and family issues. Then the therapist goes through the specific skills that will be taught during

the program that targets each dysregulation: respectively, these are mindfulness, tolerance of stress,

emotional regulation, interpersonal efficiency and dialectical thinking.

The problem behaviors identified in the behavioral chain analysis are also classified as life-threatening,

therapy-interfering, quality-of-life-interfering and both strengths and weaknesses when it comes to skills.

At this point, the client is asked to determine what their long-term goals are, and these are integrated into

the program.

During the orientation, the biosocial theory is introduced, stressing the focus on an empathic and non-

judgmental attitude. The client is also introduced to the DBT format, schedule and activities, including

how to use DBT diary cards. Treatment agreements are discussed to ensure clarity of what is expected

from the client, therapist and family in order to make DBT successful. Finally, commitment strategies are

used on both the client and his/her family.

How to conduct individual therapy

Because adolescents with BPD and/or suicidal problems tend to shy away from emotional encounters, it

is important to give them a sense of security by establishing a routine to therapy sessions. The primary

therapist in the DBT team conducts the sessions. The first step is to greet the client in a way that makes

him/her feel welcome, despite any difficulties in the therapeutic relationship.

The next step is to ask for the DBT diary cards and discuss the previous week’s events. Usually, the

therapist helps the client fill out the cards in the first few sessions to help them gain mastery. When the

client does not bring cards or has not filled them out, remind them that the session cannot go on without

it.

Have them fill it out and discuss why they were unable to accomplish the task in a non-judgmental

manner. A repeat of this behavior is considered as therapy-interfering behavior and should be dealt with

as such. The therapist must emphasize the importance of diary cards in both words and actions in every

individual session.

The agenda for the session is then discussed—this consists of problem behaviors identified in the diary

cards. The therapist must be keen at observing the emotional state of the client, and ask them if there is

anything they would like to add to the agenda. This collaborative approach encourages the therapeutic

relationship. The primary therapist may also assign homework aside from the diary cards depending on

the needs and target behaviors of the client. This is reviewed and discussed in the following session.

The primary therapist is also responsible for taking note of the full treatment progress. Updates on the

skills training session with the other assigned therapist on the DBT team is discussed, as well as any

medical appointments or treatment-related activities. At the end of the session, summarize what was

discussed and find ways to cheer them on, encourage them, and reassure them that they’re on the right

track.

Throughout the treatment, clients may act difficult—their condition often makes them scared of

confronting the behaviors they have used as coping mechanisms for so long. The therapist must prioritize

targeting problematic behaviors instead of deviating from the topic. Over time, the client will understand

that discussing what he/she is afraid of must be done for healing to occur.

Working on problematic behaviors

The majority of the individual therapy session is focused on working on problematic behaviors. The first

is to identify them in specific terms (e.g. self-cutting using a razor, not accomplishing the diary cards).

Then identify what caused this behavior—an event that happened right before that might have disturbed

the client’s thoughts and feelings.

Help them pinpoint what made them vulnerable to the event—sickness, use of drugs or alcohol, among

others. Then have them give a blow-by-blow account of what happened right before the behavior. Try to

get them to be as detailed as possible. Then ask them about the consequences of the behavior—what

happened after? Review the chain of events together and identify ways to avoid the behavior in the future.

Think of solutions from the negative consequences arising from the behavior. Finally, apply the

appropriate change procedure (e.g. skills training, exposure, cognitive modification or contingency

procedures) to teach and reinforce healthier and more effective ways of dealing with the problem.

Explaining the behavior to the client or his/her family in the context of psychological theories or studies

can help them understand the situation better and avoid blaming the client. Encouraging insight from the

client can also help.

Addressing difficult behavior during sessions

Once a dysfunctional behavior is observed during the session, describe it and communicate that it is not

helpful to getting better. Allow the client to react, then teach them what they can do when the problem

arises. Help them understand and apply new behaviors which are conducive to treatment and get them to

commit to them. Ask them to practice it right then and there—for example, if they become overwhelmed

by the therapist’s questions, they can be taught to ask the therapist “Please slow down so I can

understand”.

How to conduct telephone consultation

Consultations over the phone are done on an as-needed basis. Clients may call their primary therapist

whenever they feel like engaging in suicidal behaviors. It is important to stress the need to call before

anything happens—when they encounter extreme triggers that they cannot handle using the skills they

have learned, they are encouraged to do telephone consultation for coaching.

Client-therapist confidentiality can be broken if the therapist ascertains the client is serious about harming

him/herself. What behavior constitutes this serious breach is dependent on the therapist’s understanding

of the client, and requires critical thinking.

Stress the futility of helping if the client calls after they have harmed themselves. Should this happen, the

therapist will need to assess how much danger the client is in, ensure that medical care reaches him/her at

the soonest, and inform the client’s family member. The therapist should take care not to reinforce the

suicidal behavior during the call after.

How to include family in DBT

The inclusion of family in the sessions is the core difference between DBT for adolescents and standard

DBT. At the beginning of treatment, there must already be a commitment on at least one family member

(usually a parent) to take part in the DBT program.

The goal is to lessen the interactions within the family that fuel the client’s life-threatening behavior,

decrease the therapy-interfering behavior of the family members, reduce family behaviors that negatively

affect quality of life and increase skills such as validation, communication and dialectical thinking within

the family. Orienting the family on psychoeducation can greatly help increase empathy and a non-

judgmental stance towards the client, making it easier for them to help him/her.

Essentially, it follows the same steps as individual therapy. There is a family behavioral analysis to

determine target behaviors, skills training, and telephone consultations. A plan to deal with the adolescent

when a triggering crisis occurs is also developed and taught—this includes soothing intense emotions,

cheerleading and validating strategies.

When the adolescent threatens suicidal behavior to get what he/she wants, the parent can use the same

dialectical strategies as a therapist. This is included in their skills training sessions. It is also important to

assess the risk of the situation, or how much the adolescent means what he/she says. The concern is to act

in a way that does not reinforce the behavior.

How to conduct group skills training

Group skills training is best conducted with two therapists to lead and oversee the sessions. It is best that

group skills therapists do not serve as the primary therapist of any client in their group. In a multifamily

set-up, the family member attending the sessions should be consistent across all sessions. The decision to

keep the training closed (same set of clients and families all throughout) or to keep it open (new families

added at every module) have their own distinct advantages that should be factored in when developing the

DBT program.

The training imparts the following skill sets: mindfulness, interpersonal effectiveness, emotional

regulation and distress tolerance. Mindfulness is similar to meditative exercises—it teaches the clients

and their family members to observe, describe and experience the situation in a nonjudgmental and

effective way. Interpersonal effectiveness is essentially honing communication skills to be able to seek

help, fulfill needs, manage conflict and preserve self-respect.

Emotional regulation skills focus on managing intense negative feelings—understanding what they are

feeling, being mindful, and reducing vulnerability. Lastly, distress tolerance teaches the group to go

through difficult experiences without resorting to dysfunctional problem-solving behavior.

Given a 16-week DBT program, each skill set receives four weekly sessions of two hours each (with a 10-

minute break). The first session of each skill set involves introduction of participants and therapists,

orientation on the treatment goals, rules and signing of the agreement to participate in the session. The

next three sessions start with a mindfulness exercise, presentation of skill set materials (including skills

handouts), and homework exercises.

Adolescent group skills training is more effective when games and other interactive exercises are used.

Core mindfulness is taught through identifying and describing emotional states—the use of charades to

convey feelings and learn how to recognize and label them is one activity. Mindfulness is a skill integral

to all aspects of treatment, and it is usually integrated into the other sessions.

In distress tolerance sessions, various relaxing props to soothe each of the five senses is presented. The

clients are given time to use them and understand how self-soothing is done. Materials to distract from

negative emotions are also used in session—funny video clips, magazines, manicure kits, among others

are provided.

Interpersonal effectiveness sessions are conducted in role-play fashion. A sample situation is given

wherein the adolescents are paired with adults (can be his/her family member or someone else’s). They

can also be presented with a hypothetical problem their skills trainer is experiencing, and be asked to

provide advice on how to handle the situation effectively. They practice using each of the modules in the

interpersonal effectiveness arsenal.

Emotion regulation is also taught experientially. A difficult situation is given that all group members can

relate to, and the group is asked to map out the changes that occur when something distressing happens.

The use of videos to evoke emotion and reactions are also helpful in this exercise—clients can then

practice nonjudgmental observation of how they feel, and focus on how they personally experienced the

film.

The fifth module was developed especially for DBT application to adolescents. This deals with parent-

adolescent relationship dynamics and how to make them more balanced. This includes how to validate an

adolescent’s personal experience, and how to induce behavioral changes using reinforcement, shaping,

extinction and punishment. For the parents, this helps them create a validating environment that reinforces

positive behavior and reduces dysfunctional ones.

Assessing treatment progress, graduation and post-program support

Regardless of the program length, a client is kept within Stage 1 of the DBT until the dysfunctional

behaviors subside. They may undergo a more intensive form of the treatment stage in order to move on to

the next stage: Stage 2 that deals with post-traumatic stress through exposure. The client graduates to the

next stages as improvement is seen. When the client appears to resist change, the DBT team does a

thorough review of what needs to be adjusted in the program—increase motivation of the client and/or

family members, additional training for the therapists, among others.

To assess whether the client is improving, the primary therapist monitors the content of the diary card,

reduces target behaviors as seen in individual sessions and group sessions, and witnesses enhanced family

interactions. These should comprise both personal observations and the observations of the DBT team.

Formal measures, much of which are similar in format to written exams, will be conducted.

In case a client completes suicide, the therapist should provide empathic support to the family. He/she

should lean on the DBT team to manage the range of emotions and to avoid placing blame on the client

him/herself or the family. Members of the skills training class also need to be helped through accordingly.

Giving post-program support through a graduate treatment group is helpful in preventing relapse and

transitioning out of therapy. It places emphasis on peer learning and encourages clients to teach the skills

instead of relying solely on the skills training therapist. The program consists of weekly group therapy

sessions and therapist consultation sessions.

Usually the former is a two-hour session that includes a mindfulness exercise, virtual diary card review

(filling out the cards is no longer a requirement in the graduate program, but it may be easier to discuss

based on the format the clients have gotten used to), review of skills learned during the program,

consultation and problem solving (where the clients are encouraged to practice their validation, soothing

and critical thinking skills on their group mates) and closing. Telephone support, individual or family

therapy sessions and pharmacotherapy are provided on an as-needed basis.

Treatment can be terminated on other grounds—the client enters college, the parents decide to cease

treatment, or if the program is conducted as a research. As much as possible, preparation should be made

to transition the client out of the program. If necessary, referrals can be made to provide support to the

client.

Handling issues about the DBT program

It is helpful to think of hindrances to the DBT program as “program-interfering behaviors” and applying

the same practices employed to target therapy-interfering behaviors in clients and families.

It is important to assess the need for DBT in the area where a program is being considered. Financial

resources, staff recruitment and training, and concerns about starting a program geared towards suicidal

adolescents (a population known to be difficult to manage) should be addressed. There may be different

parties that have issues, but with accurate information and proper communication of the benefits, resource

requirements and theories behind DBT, these worries should be addressed.

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