If you’re reading this, you’re probably trying to figure a lot of stuff out right now and you’re doing your research. If I had to guess, you’re probably the parent or caregiver of a teen who’s struggling with their mental health or you’re the teen that’s struggling (or maybe you’re someone who likes reading mental health blogs for all I know!). Regardless, I know that starting the process of getting connected to a therapist and starting mental health treatment can be incredibly daunting. There are so many different types of therapy available and, if you’re not in this field or up-to-date on the latest mental health developments, how on earth are you supposed to know what next steps to take?! There are so many things to consider at this step of the process. I’m hoping to give you some information on DBT and answer some common questions we get in the hopes of making this process just a smidge easier for you.
WHAT IS THE MOST EFFECTIVE TX FOR ADOLESCENT DEPRESSION?
There are many studies out there to answer this very question. Realistically, a lot will depend on what the teen is going through and their own personal preferences and experiences. Overall, research seems to show the effectiveness of these treatments on adolescent depression, more information on these can be found in the sources listed below:
- Cognitive Behavioral Therapy (CBT)
- In terms of the research, currently, CBT is considered the most effective treatment for adolescent depression.
- CBT focuses on addressing negative thought patterns and behaviors that contribute to depression.
- Dialectical Behavior Therapy (DBT)
- Research shows that DBT is effective for treating a wide range of disorders including depression, anxiety, personality disorders, etc. as well as addressing and reducing problem behaviors like non-suicidal self-injury, suicide behaviors, substance use, eating disorders, etc.
- A skills building program that is time-limited and includes building skills in mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness
- This therapy includes individual therapy, group therapy, 24/7 access to phone coaching with the individual therapist, and the therapist meets with other clinicians on a regular basis for support and consultation
- More info on this treatment can be found throughout our website and in other posts
- Eye-Movement Desensitization and Reprocessing (EMDR)
- Research has shown the effectiveness of EMDR in addressing various mental health diagnoses including anxiety, depression, PTSD, OCD, substance use, etc.
- Trauma-focused approach
- Utilizes bilateral stimulation (BLS) to help the brain reprocess various traumatic memories and help shift people into more effective, adaptive thinking.
- More information on this approach can be found on this site and in other posts
- Interpersonal Psychotherapy for Adolescents (IPT-A)
- Evidenced-based to treat depression
- Focuses on the relationship between mood, interpersonal, and environmental factors.
- Time-limited approach, treatment occurs in three phases
- The initial phase focusing on psychoeducation, treatment planning, and assessing
- The middle phase includes focusing on each area in depth and learning skills and problem-solving
- The termination phase includes a review of what was learned, progress made, and feelings about treatment ending
CAN DBT BE USED WITH ADOLESCENTS?
Yes, DBT was initially created to address self-harm and suicide behaviors in adults. After discovering how effective DBT is in reducing these behaviors, DBT was adapted to address a wide range of mental health disorders, emotion dysregulation, and other behavioral concerns. In addition to this, the DBT model has been adapted to work with adolescents. Dialectical Behavior Therapy for Adolescents (DBT-A) is directed towards youth ages 13-18. The adolescent model contains the cornerstone structure and skills of the initial model, adjustments were made for the emotional and cognitive developmental level of teens. The adolescent model also addresses concerns specific to teens such as attending school, living with family, and daily functioning as someone dependent on those in their environment for support.
At Cincinnati Center for DBT, our adolescent program includes:
- Individual psychotherapy for the teen. This usually takes place on a weekly basis and the focus is on identifying target behaviors, assessing what contributes to those behaviors occurring, and applying skills to address those concerns in healthy and effective ways.
- Multifamily group in which a teen and one caregiver attend and complete the group together. This group meets once a week for 2 hours. Group is a place for teen and caregiver to learn the skills together and complete homework aimed at building mastery at these skills. Mindfulness, emotion regulation, distress tolerance, walking the middle path, and interpersonal effectiveness are the 5 sets of DBT skills and group is spent learning skills in these areas.
- Phone coaching– the teen has access to 24/7 phone coaching with their therapist. This is aimed at helping the teen apply the skills they’re learning in the moment, when the problem is happening. Phone coaching can be used to help clients while they’re experiencing self-harm and/or suicidal thoughts and urges, while trying to use the skills to address day-to-day stressors, and in any times when they’re experiencing concerns with their therapist or within their relationship. The parents can have access to phone coaching for help with parental support.
- Finally, the therapists take part in a consultation team. DBT believes in a community of providers serving a community of clients. You won’t just have one therapist working with your child, you have an entire team. Consultation team is meant for the therapist to address concerns they’re having, receive consultation on client issues, and receive support as needed.
More information on our adolescent program can be found on our website.
CAN DBT BE USED FOR ADOLESCENT DEPRESSION?
Yes, DBT is effective for adolescent depression. DBT, and DBT-A, focuses on identifying and addressing “problem behaviors” that contribute to emotion dysregulation, which includes depression. The skills modules taught in group help increase skills in mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Mindfulness skills can help individuals decrease suffering and increase happiness, increase control of their mind, and experience reality as it is. Emotion regulation helps people understand and name their emotions, decrease the frequency of unwanted emotions, decrease their emotion vulnerability, and decrease emotional suffering. Distress tolerance skills teach people to survive crisis situations without making it worse and accept reality and become unstuck. Finally, interpersonal effectiveness skills help individuals be skillful in getting what they want and need from others and saying ‘no’ effectively, build and strengthen relationships, and walk the middle path. All of these skills can be so helpful and effective in addressing internal and external factors that contribute to depression. And that’s just skills training group! In individual therapy, teens will be able to work with their therapist to apply these skills to their own specific situations and learn effective ways to address emotional dysregulation and maladaptive behaviors. Phone coaching can help your teen address concerns in their daily life in safe and effective ways WHILE it’s happening, instead of addressing it in session AFTER the situation and planning on what to try and do next time.
WHAT IS THE SUCCESS RATE OF DBT FOR DEPRESSION?
Research shows a significant reduction of depressive symptoms after completing comprehensive DBT. While a study has not been done to show the success rate of DBT for depression in teens, a study determining the effectiveness of DBT in treating treatment-resistant depression in adults showed that up to 60-80% of participants in studies show clinically significant improvements in depressive symptoms after undergoing DBT.
Notably, DBT is also notably effective in reducing suicidal thoughts and behaviors, which is often (not always) experienced by people with depression. Research also suggests that DBT for depression can be long-lasting, with sustained improvement in symptoms reported months after completing therapy.
IS CBT OR DBT BETTER FOR DEPRESSION?
Both CBT and DBT can be effective for treating depression, it’ll depend on your specific needs and circumstances in deciding which would be a better fit for you. CBT primarily targets unhelpful thought patterns and behaviors that contribute to depression. DBT primarily targets emotion dysregulation by teaching skills such as mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. CBT may be a better fit if you find your depression is primarily driven by negative thinking patterns. DBT may be a better fit if you find that your depression coexists with emotion dysregulation, relationship concerns, self-harm, and/or other concerns.
Both treatments have been proven to be effective for treating depression through various research studies conducted over the years. It’ll be worth doing your research to see which approach may be a better fit for you and your needs.
HOW LONG DOES IT TAKE FOR DBT TO WORK?
Short answer- studies show a decrease in mental health symptoms and maladaptive behaviors after participating in the comprehensive DBT program for at least 6-months, though most studies are conducted on individuals who completed a full year of a comprehensive DBT program.
The DBT program at CCDBT requires a 6 month, or 24 week, commitment. As people near the end of their commitment, they’ll be given the option to recommit for an additional 6-months or graduate from group and/or individual therapy. CCDBT asks for a 6-month commitment from clients to balance giving clients effective, adherent care with the knowledge that the cost of treatment can really add up. Each individual’s experience will differ based on what they’re coming into treatment with.
Overall, while 6-months and 12-months can be an intimidating commitment, DBT is meant to be a time-limited treatment so that people can experience real change in their symptoms and actually be able to stop going to therapy when they reach their goals. Many people have spoken to the experience of going to other forms of talk therapy and feeling like they experience minimal improvement, even over extended periods of time. So while this commitment might be intimidating, participating in comprehensive DBT may be the most effective route to be able to reach a reduction of your symptoms enough to feel comfortable stopping therapy.
WHY IS DBT CRITICIZED?
There are a few common criticisms of DBT to be aware of while considering your options. This presents another opportunity for practicing dialectics- these criticisms can be very valid based on individual clinicians who practice ADHERENT DBT, meaning, clinicians who have been extensively trained in DBT and are providing DBT treatment based on the principles outlined by Marsha Linehan. Many clinicians state they are providing DBT therapy without engaging in the research and training required to provide competent and adherent care, which unfortunately can lead to clients having adverse experiences in treatment. We have a whole post on the importance of finding effective DBT clinicians and how to do so, so you can read more on that here (hyperlink post on this plz).
That all being said, let’s get into some of these criticisms!
Rigidity and Intensive Commitment
DBT is big into being nonjudgmental, so I’m going to reframe this criticism nonjudgmentally- DBT is an intensive treatment that requires clients to commit to a 6-month commitment (at least, CCDBT requires a 6-month commitment as described above. A lot of DBT programs may require a 12-month commitment) of meeting with their individual therapist for one hour a week, on top of a two-hour group. Plus, clients will be expected to complete a diary card and homework assignments for individual therapy and group and make various agreements such as committing to refrain from self-harm and suicidal behaviors while in treatment along with other commitments. DBT asks a lot of its clients, that’s not lost on me. This is done because making lasting, meaningful changes that help clients reach their life worth living goals
DBT also uses what’s called a target hierarchy that prioritizes what will be discussed in each session and prioritized in treatment overall. The hierarchy order, just for general context is to address any life-threatening behaviors first, then any therapy-interfering behaviors second, and quality-of-life-interfering behaviors third. If there’s nothing in the first category, the therapist and client would move to the second and then the third. For instance, if anything life-threatening happened, that will be discussed over concerns like relationship problems, for instance. While this may be bothersome for clients, there’s a lot of reasons why DBT is set up this way, and it’s all to help address clients’ main concerns. One reason is that clients cannot meet their other life goals if they’re dead, hence why life-threatening behaviors are given such high priority. Also, it’s hard to address quality-of-life-interfering behaviors if a client is regularly showing up late to therapy and/or doesn’t complete between session tasks, for instance. I understand that sometimes several things happen from week-to-week for my clients and I don’t mean to diminish their wants and needs by sticking to the hierarchy, I just know that it can be easy to get lost in the ‘crisis of the week’ every week and not make much progress in therapy. Sticking to the hierarchy, while rigid at times, helps clients be more successful achieving their long-term goals.
Cultural Limitations
This is actually something our team at CCDBT discusses frequently. It can be easy as clinicians, whether DBT, CBT, etc., to view the world from their limited frame of reference and not take into account the culture of their clients and how that plays a role into their thoughts, emotions, and behaviors. The DBT community as a whole is working to address the cultural limitations of the treatment modality and is working to increase the cultural competency of clinicians.
At CCDBT, we’re committed to addressing any cultural limitations by reading and completing trainings surrounding other cultures and challenging any growth areas within ourselves. In our weekly team meetings, we have a list of agreements we agree to and review weekly to help us stay grounded in providing culturally competent care. We also highly encourage each other to bring up concerns in team meetings so we can provide consultation to each other to address our own biases, provide other mindsets or frameworks to consider in addressing client concerns, and challenge each other to consider factors outside of our own worldview.
Challenging for those with Cognitive Limitations
This is another criticism that isn’t necessarily untrue. DBT in its original form requires a degree of cognitive engagement and flexibility to learn and apply the skills and understand the nuances of the various skills. Those with cognitive limitations whether due to intellectual disabilities, neurocognitive disorders, difficulties in memory, TBIs, etc., may find the original structure of DBT to be difficult to grasp or comprehend. That being said, DBT can still be helpful for someone with cognitive limitations.
There are adaptations to the DBT model to make the skills easier to understand for those with cognitive limitations as well. There are also things that clinicians can do to tailor treatment to the needs of this population as well. For instance, clinicians can take a more direct and focused approach to teaching the skills and use more concrete examples while teaching the skills. DBT can be effective for those with cognitive limitations, it will be helpful and important to verbalize concerns and collaborate with your provider if this is the case for you.
Overemphasis on Emotional Regulation and Behavioral Change
This is another criticism of DBT that has some truth to it and there are definitely some pros and cons to consider when deciding whether or not DBT is the right fit for you. DBT is a therapy that focuses on emotion regulation and changing behaviors, whether that’s an ‘overemphasis’ on these areas or not, is another story.
To address the pros- DBT is aimed to help individuals learn about, understand, tolerate, and manage their intense emotions, which can be overwhelming for some. Many people are never taught how to regulate their emotions in healthy and effective ways, leading them to develop coping mechanisms that are ineffective or unlikely to be sustainable long-term (self-harm, suicide behaviors, avoidance behaviors, etc.). Learning other ways to manage these emotions can lead to symptom reduction and improve overall functioning.
In terms of focusing on behavioral changes- there is a lot to be said about trying something, finding that it works, and then feeling better. While that’s vague, I can think of tons of examples in my life where I made a behavioral change which had a large rippling effect in my life overall. For instance, learning how to communicate more directly with my significant other made me feel much better in my relationship, I am much better able to get my needs met and clarify any areas of discomfort, frustration, or miscommunication. Then I found those communication skills are applicable to my family and even my boss. I can communicate better in all these different areas, get my needs met, and address concerns across the board because I learned the skills to do so starting with my significant other. While this is just one example, it demonstrates how powerful changing behavior can be and how much of a rippling effect it can have on other areas of life.
Those who believe there is an overemphasis in these areas may not fully understand how DBT works or may have worked with a clinician who did not balance other important factors of the treatment. Those who have this criticism of DBT believe that DBT does not get at the root of problems and can lead to clients believing they need to be over-controlled in their emotional responses or even suppress their emotions. DBT is big on the ‘dialectics’ (D=dialectical). The major dialectic in DBT is balancing acceptance and change. If a clinician is too change-oriented, a client may experience DBT in this way, and may find that they are focusing too much on change and not learning how to accept emotional states and learn from them. Bringing in the acceptance portion and finding that balance between acceptance and change can help mitigate these concerns and help clients find a balance of learning how to regulate and change their emotions and maladaptive behaviors while also learning how to accept various aspects of their emotional states.
It is also very common for people to come to DBT to learn how to tolerate negative emotional states in a safe and effective way, complete the 6-month program, learn these basic skills, and then move on to other forms of therapy because they have these skills under their belt. DBT does not claim to be an end-all-be-all type of treatment. It’s completely valid for clients to get a basic understanding of their emotions, how to manage or eliminate maladaptive behaviors, and work towards finding that balance of acceptance and change, and then take what they’ve learned and utilize that as they pursue other forms of therapy or be done with therapy all together!
IS DBT BAD FOR TRAUMA?
For a quick and simple answer- no, DBT is not ‘bad’ for trauma. As a clinician at CCDBT, I specialize in DBT and EMDR (reminder- EMDR is a trauma-focused treatment). I’ve found that my clients that start with DBT are able to transition into EMDR and do trauma work more smoothly because they have the foundational skills that DBT provides in being mindful of their emotions, thoughts, body sensations, and behaviors, they have skills to regulate their emotions and tolerate distress, and they’re better able to communicate their needs to me and others in their environment. DBT can help reduce trauma symptoms in people and there are additional stages of DBT that specifically address trauma once someone is able to effectively regulate their emotions. There is even a trauma protocol (DBT-PE) that works with trauma using prolonged exposure.
RESOURCES:
“Dialectical Behavior Therapy Decreases Depressive Symptoms Among Adolescents in an Acute-Care Inpatient Unit” –https://www.liebertpub.com/doi/10.1089/cap.2019.0149#:~:text=of%20specific%20interest.-,Clinical%20Significance,require%20acute%2Dcare%20inpatient%20treatment.
Dialectical behavior therapy for nonsuicidal self-injury and depression among adolescents: preliminary meta-analytic evidence
https://acamh.onlinelibrary.wiley.com/doi/abs/10.1111/camh.12112
Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: a systematic review and meta-analysis
Dialectical Behavior Therapy as an intervention for Treatment Resistant Depression in adults: A protocol for systematic review and meta-analysis
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0303967
Effectiveness of trauma-focused treatment for adolescents with major depressive disorder
Interpersonal Psychotherapy for Depressed Adolescents
Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder
Peprah K, Argáez C. Dialectical Behavioral Therapy for Adults with Mental Illness: A Review of Clinical Effectiveness and Guidelines [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Oct 20. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525629/