Editor's note: This article was sponsored by THIRA Health.
The stigma against seeking mental health help is fading (though attitudes are nevertheless very slow to change), but finding a therapist is harder than finding a doctor or a dentist. We don’t always know what to look for, there are a lot of different approaches, and it can seem like there’s more theory than data about what works — especially when it comes to accessing care for teens.
But science is catching up with practice, and one approach is pulling ahead of the pack for helping teens at highest risk.
Dialectical behavior therapy
“[Dialectical behavior therapy] was developed for folks who have a biological or acquired vulnerability toward being the more emotional people of the world. They have a lower threshold for an emotion to fire; once active, the emotion spikes high, and there is a slow return to baseline. This alone is not a problem — in fact [without these people], we’d not have the poets, artists and great dreamers of the world!” says Kathryn Korslund, Ph.D., chief clinical officer for THIRA Health, a Bellevue, Washington, treatment center created exclusively for women and girls. But individuals who are more vulnerable to emotion need stronger coping skills to avoid becoming overwhelmed.
Dialectical behavior therapy, or DBT, is a therapeutic approach that pairs the empathetic validation of traditional therapy with practical problem-solving. Through this balance, DBT aims to change the unfavorable patterns associated with coping with problems in life, while promoting inner wisdom, or “wise mind.”
Developing a ‘wise mind’
“At its center, ‘wise mind’ is knowing something based on the synthesis of both reason/fact and emotion/intuition,” explains Korslund. It is easy to lose touch with the wise mind when one is caught up in emotion. Korslund says that in times of stress, parents may listen to the latest parenting fad or well-meant advice of friends and family over their own deep knowledge of themselves and their children.
“Mindfulness practice is a great way to quiet the mind from the incessant tyranny of our thoughts, self-demands and desires. In the quiet, wise mind speaks,” says Korslund.
Parental involvement is key
“Change does not occur in a vacuum but rather as part of a series of transactions in the environment, and for kids, a key part of that environment is the parents. In DBT, parents are taught the same skills that teens learn,” says Korslund. When both parents and teens apply the skills, they each change the environment, contributing to positive change.
However, this does not mean that parents are privy to everything that happens in therapy. As with other forms of therapy, DBT requires strict confidentiality, except where there is an immediate risk of harm.
“While therapists typically try to move kids toward a more open dialogue with their parents, for the therapist to continue to receive information to help manage risk and promote treatment goals, the child needs to feel confident that reports to the therapist will not generate reports to parents,” says Korslund.
Validation
“Validation helps a parent convey to their child that they see and hear them; their experience, emotion and perspective. Conveying that understanding, even when offering a different view or standing by a decision, at least ensures that the other party knows that they are understood,” says Korslund. “Ultimately, validation is about paying attention — really paying attention. Put down the cellphone, stop checking email or social media, and convey that you really, really understand.”
This kind of attention involves careful listening and empathy. It requires parents to resist the impulse to jump right in with explanations and solutions. But it does not involve letting go of one’s own perspective and experience.
“Giving the kiddo chocolate as their dinner entrée because we don’t want to invalidate their private experience that chocolate tastes good is not the goal. We can validate that they want that because it indeed does taste good and still stick to a nutritious dinner,” says Korslund.
Coaching
Validation (communicating that the child’s inner world makes sense) is complemented by coaching (helping the child deal with the disappointment of chicken instead of chocolate). In true DBT form, an effort to find a synthesis in the chocolate versus chicken debate may include a little of both: chicken in mole sauce! And while chocolate is a fun example, DBT is literally applicable to matters of life and death.
A clinical trial published in the Journal of Child Psychology and Psychiatry in 2019 found that DBT was more effective in reducing self-harm (including suicide attempts) in high-risk teens than traditional therapy.
Learning modules
The coping skills taught in DBT are presented through four educational modules that include lessons and assignments.
Mindfulness
“With practice, acceptance of the moment — life! — on the moment’s terms decreases suffering and can bring freedom and joy,” says Korslund.
Mindfulness teaches what to do (observe, describe, participate) and how to do it (nonjudgmentally, focusing on one thing and being effective). Staying in the present replaces ruminating about the past with intentional reflections on the past. It replaces worrying about the future with planning for the future.
Interpersonal effectiveness
This module teaches teens how to make requests in the best way to get the answer they want, as well as how to say no without backing down. Although parents often worry about their kids using these strategies against them, this approach is actually the opposite of manipulation.
“Being an emotionally dysregulated person and/or having behavior patterns that are distressing to others as well as one’s self erodes or interferes with solid interpersonal relationships,” says Korslund. Interpersonal effectiveness replaces threats and capitulation with the establishment of effective navigation in the give-and-take of relationships.
Distress tolerance
This module teaches crisis survival skills: how to avoid making a crisis worse and how to accept the reality of painful events or circumstances. Acceptance doesn’t mean giving up; it is the first step to making change.
“Pain is a necessary part of life. Suffering, however, is pain plus nonacceptance of pain. Learning to accept the moment — radically, genuinely — is the way out of torment,” says Korslund.
Emotion regulation
This module has a lot in common with the social-emotional curricula taught in schools, but specifically targets people dealing with emotional dysregulation. It teaches the evolutionary or biological purpose of emotions, how to identify emotions, and how to decrease and recover from dysregulated emotions.
Getting help when you need it
Like other types of social-emotional learning, DBT modules teach basic life skills that people are seldom explicitly taught. Most of us simply muddle through on our own, but the extra support and training provided by DBT can be critical, especially for people who are suffering from emotional dysregulation.
Because no one is immune to becoming overwhelmed, the most important coping strategy may be recognizing when you need help, regardless of which therapeutic approach you pursue.
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