DBT for Teens: What DBT-A Involves and How to Decide Whether It Fits Your Child

About this tool

DBT for teens, known in the research as DBT-A, is dialectical behavior therapy adapted for adolescents. Dialectical behavior therapy was developed by the psychologist Marsha Linehan in the late 1980s and early 1990s for adults with chronic suicidal behavior and what was later diagnosed as borderline personality disorder. It combines cognitive behavioral change strategies with acceptance and mindfulness, and its name refers to holding two truths at once: a person is doing the best they can, and they need to do better. In the late 1990s the psychologists Jill Rathus and Alec Miller, working in the Bronx with adolescents who had attempted suicide or were self-harming, adapted the adult model for teenagers and their families. That adaptation is what most clinics mean by DBT for teens.

A full DBT-A program has several parts, and a parent should expect all of them. Weekly individual therapy for the teenager, working from a diary card and a hierarchy of targets: life-threatening behavior first, then anything that interferes with therapy, then behavior that gets in the way of a life worth living. A weekly multi-family skills group, usually around two hours, in which teenagers and parents learn the skills together. Telephone or text coaching between sessions, so the teenager, and in most programs the parents, can get help using a skill in the moment. Family sessions when a specific problem needs working through. And a weekly consultation team for the therapists, which is part of the model, not an optional extra. Programs usually run sixteen to twenty-four weeks, sometimes six months, often followed by a graduate group.

The skills are taught in five modules. The four standard DBT modules are mindfulness, noticing what is happening inside and outside without immediately reacting; distress tolerance, getting through a crisis without making it worse; emotion regulation, understanding what emotions do, reducing vulnerability to them and changing an emotion that does not fit the facts; and interpersonal effectiveness, asking for what you need and saying no while keeping the relationship and your self-respect. Rathus and Miller added a fifth, Walking the Middle Path, written for teenagers and parents together. It teaches dialectical thinking, both-and rather than either-or; validation of yourself and each other; and the basic principles of behavior change, so parents understand what reinforces a behavior and what extinguishes it.

Walking the Middle Path exists because Rathus and Miller noticed that families of struggling teenagers swing between extremes, and they named three such dilemmas. Excessive leniency versus authoritarian control: parents who have given up on rules, and parents who have made rules the whole relationship. Normalizing pathological behavior versus pathologizing normal adolescent behavior: shrugging off self-harm as a phase, or treating ordinary moodiness as a crisis. Fostering dependence versus forcing autonomy: doing everything for a teenager who cannot cope, or demanding they manage alone before they can. The middle path is a synthesis, not a compromise, and the module gives parents and teenagers the same language for finding it. This is why parents attend: the skills are for the family's patterns, not only the teenager's.

The evidence is strongest for exactly the problem the adaptation was built for: repeated self-harm and suicidal thinking. A randomized trial in Norway led by Lars Mehlum, published in 2014, compared nineteen weeks of DBT-A with enhanced usual care in seventy-seven adolescents with repeated self-harm and found larger reductions in self-harm, suicidal ideation and depressive symptoms, with the self-harm advantage holding at one year. A larger American trial led by Elizabeth McCauley, published in 2018, compared six months of DBT with an active supportive therapy in 173 adolescents at high risk for suicide: DBT produced fewer suicide attempts and less self-harm at the end of treatment, and by twelve months both groups had improved and the difference was no longer significant. A 2021 meta-analysis by Kothgassner and colleagues pooled the trials and found DBT-A reduced self-harm and suicidal ideation compared with control treatments. The caveats: few trials, varied comparison treatments, and no established long-term advantage over good alternative therapy.

DBT-A fits a teenager, roughly twelve to eighteen, with repeated self-harm, suicidal thoughts or attempts, or emotions so intense and fast-changing that they regularly lead to crises, broken relationships, risky behavior or school breakdown. Many of these teenagers also have depression, anxiety, an eating disorder, substance use or traits of borderline personality disorder, and DBT-A can hold those together rather than treating them one at a time. It is a less obvious fit when the main problem is something else with its own well-evidenced treatment, such as a specific anxiety disorder without emotion dysregulation, or when a teenager is acutely psychotic or so unwell that an inpatient or crisis service is needed first.

Two things parents mix up are worth separating. The first is comprehensive DBT versus DBT-informed therapy. Many therapists use DBT skills in ordinary individual therapy and call it DBT, and it can help, but it is not what the trials tested. The trials tested the full package: individual therapy, skills group with parents, coaching between sessions and a consultation team. For a teenager who is self-harming or suicidal, ask for the full package, and ask which components a program offers. The second is DBT for teens versus the DBT skills workbooks sold for teenagers. A workbook can support treatment and is not treatment. This page does not teach your teenager skills and is not meant to; the skills are taught in a group, by a trained therapist, with you present.

What parents actually do in DBT-A: attend the skills group every week and practice the skills themselves, because teenagers notice when the adults are exempt; learn to validate, which means communicating that a feeling makes sense without agreeing with the behavior; use coaching calls while a situation at home is escalating rather than after it has blown up; and complete the parts of the homework that belong to them.

Finding a program: look for a team rather than a single therapist, ask whether the therapists have intensive DBT training and whether the program or its clinicians are certified by the DBT-Linehan Board of Certification, and ask which components they run. The Psychology.com directory lets you search for therapists who work with adolescents and list dialectical behavior therapy as a modality. If your teenager is in immediate danger, none of this is the first step: in the US, call or text 988, go to an emergency department, or call your local emergency number. Ask any program what their plan is for a crisis between sessions, and do not accept a vague answer.

Reviewed by Michael Callans, MSW
Checked the DBT-A components, the five modules including Walking the Middle Path, the three dialectical dilemmas and the trial summaries against Rathus and Miller and the cited trials.

References

1. Miller AL, Rathus JH, Linehan MM. Dialectical Behavior Therapy with Suicidal Adolescents. Guilford Press; 2007.
2. Rathus JH, Miller AL. DBT Skills Manual for Adolescents. Guilford Press; 2015.
3. Mehlum L, Tormoen AJ, Ramberg M, et al. Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2014;53(10):1082-1091.
4. McCauley E, Berk MS, Asarnow JR, et al. Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: a randomized clinical trial. JAMA Psychiatry. 2018;75(8):777-785.
5. Kothgassner OD, Goreis A, Robinson K, Huscsava MM, Schmahl C, Plener PL. Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: a systematic review and meta-analysis. Psychological Medicine. 2021;51(7):1057-1067.

DBT for Teens (DBT-A) FAQ