Dialectic Behavior Therapy

Dialectic behavior therapy (DBT) was developed by psychologist Marsha Linehan to help adults regulate emotions, tolerate distress and improve their interpersonal relationships. Over the past several decades, DBT has been adapted for children and teenagers who struggle with internalizing disorders as well as those troubled by thoughts of suicide and self-harm.

The premises of DBT is that individuals can live a life of meaning and consistency with their values while simultaneously living with painful emotions. Extensive research has shown DBT to be effective in reducing suicidal ideation, symptoms of depression, substance use and relationship conflict in both youth and adults. Although primary care providers will not be the principal provider of DBT therapy, there are DBT skills that can be integrated into wellness visits to help improve the mental health of all young people.

The following sections offer a broad overview of two fundamental concepts that serve as an introduction into how this therapy helps support kids and teens in living a more effective and meaningful life.

Mindfulness and mind states

The foundation of DBT is mindfulness, the act of paying attention on purpose to the present moment and being fully aware of what is happening in and outside of yourself. DBT teaches youth:

• to observe their experience
• stay present with both pleasant and difficult emotions
• develop a stance of curiosity about their internal world
• practice describing these experiences without judgment

As teens practice being in the present moment, they can develop awareness of the three mind-states they may be operating in at any given time: reasonable mind, emotional mind and wise mind. Reasonable mind is focused on intellectual thinking, attention to facts and use of rationalization to determine behaviors. In contrast, emotional mind is controlled by feelings. Youth tend to act in a way that is consistent with the intensity of their emotional experience when they are in this state of mind (e.g. I’m angry at my parent so I scream and throw things).

The place where these two states converge is known as wise mind, which allows youth to recognize facts while also acknowledging their feelings. This mind-state increases the opportunity to choose effective actions rather than be reactive to only one part of their internal experience. The mind-states framework can be helpful as a framing device. Teens can consider whether their behaviors are coming from reasonable or emotional mind, as well as ways they might respond differently if they were seeing a situation through their wise mind.

Discussing mindfulness with patients and parents is a small and simple way that primary care providers can help youth to become more aware of their internal mind-state. Providers might have youth complete a short breathing practice where they focus on their breath going in and out of their body for one minute. Before the activity, youth are instructed to notice when their mind becomes distracted, to identify what has distracted them (thoughts, sensations, emotions) and, once they notice the distraction, to return focus back to breathing. This exercise, followed by a debrief of what the youth noticed during the activity, helps model a skill that has positive long-term consequences for both teens’ physical and mental health, which they can practice daily.

Distress tolerance

Distress tolerance is the ability to experience intense and overwhelming emotions without taking action to change or remove the distressing feelings. When youth are in a heightened state of emotional distress, they are at risk for acting impulsively to escape the painful experience. These impulsive behaviors often provide immediately relief (e.g. using substances, self-harming) but come with unintended consequences that result in long-term problems and increased levels of stress.

This destructive feedback loop leads to more distress, followed by an increased use of impulsive destructive behaviors to cope. To help break this cycle, DBT teaches teens a comprehensive set of distress tolerance skills that help teens move through overwhelming emotions until the distress naturally dissipates. As teens experience “riding the wave” of distress, they learn that emotions come and go and that they can survive distress without having to change it or run from it.

DBT also teaches constructive coping skills for dealing with intense emotions: temperature, intense exercise, paced breathing and progressive muscle relaxation. These are referred to as DBT TIPP skills for short. These skills designed to help youth respond to situations where they are entangled in emotional mind. The TIPP skills can help to reset the body’s physiological response, lowering the arousal state and allowing for improvements in the brain’s ability to process information. The skills are easy to remember, practice and employ:

• Temperature: This skill involves exposure to cold temperatures by putting the face in a bowl of cold water or placing a cold pack over the eyes and cheeks for 30 seconds. This sudden exposure of the face to cold temperatures helps the body calm down quickly.
• Intense exercise: The body can also be calmed by engaging in short bursts of aerobic exercise (10 minutes). Running, jumping rope or doing pushups or jumping jacks can help expend stored-up physical energy.
• Paced breathing: Slowing down the pace of breathing can have a calming effect. This is done by taking in a slow deep breath (counting in your mind to 4), holding the breath in (counting to 1) and then releasing the breath more slowly (counting to 5 or 6). Doing this for 1 to 2 minutes helps bring arousal levels down.
• Progressive muscle relaxation: Starting with the feet, slowly focus on major sections of the body (legs, abdomen, chest, arms, shoulders, face) tensing muscles in those areas for 5 seconds and then releasing. Focus on the tension leaving the body as muscles are tightened and released.

Consider having conversations with youth and families about the common and uncommon stressors they are facing, as well as the frequency and intensity of these stressors. Briefly explore with youth how they respond to stress and the range of coping strategies they are utilizing. Introduce the TIPP skills and discuss situations where the youth could use these strategies to help them better cope with distressing events.

Mental health resources

DBT is an effective treatment for youth experiencing significant depressive symptoms that impair their functioning or for youth who are struggling with engagement in impulsive behaviors, self-harm or ongoing suicidal ideation. The Pediatric Mental Health Institute and Children’s Hospital Colorado offers both individual and group DBT for teens. Additionally, Partners for Children’s Mental Health offers a free online training on ways you can implement DBT skills with youth.