Dialectical Behavior Therapy For Adolescents: Theory, Treatment Adaptations, and Empirical Outcomes

Clin Child Fam Psychol Rev (2013) 16:59–80
DOI 10.1007/s10567-012-0126-7
Dialectical Behavior Therapy for Adolescents: Theory, Treatment

Adaptations, and Empirical Outcomes
Heather A. MacPherson • Jennifer S. Cheavens •
Mary A. Fristad
Published online: 8 December 2012

Ó Springer Science+Business Media New York 2012
Abstract Dialectical behavior therapy (DBT) was originally aforementioned disorders and problem behaviors. Thus, the
developed for chronically suicidal adults with borderline theoretical underpinnings of DBT suggest that this treat-
personality disorder (BPD) and emotion dysregulation. ment is likely to be beneficial for adolescents with a broad
Randomized controlled trials (RCTs) indicate DBT is array of emotion regulation difficulties, particularly und-
associated with improvements in problem behaviors, erregulation of emotion resulting in behavioral excess.
including suicide ideation and behavior, non-suicidal self- Results from open and quasi-experimental adolescent
injury (NSSI), attrition, and hospitalization. Positive out- studies are promising; however, RCTs are sorely needed.
comes with adults have prompted researchers to adapt DBT
for adolescents. Given this interest in DBT for adolescents, Keywords Dialectical behavior therapy Adolescents
it is important to review the theoretical rationale and the Emotion dysregulation Treatment adaptation
evidence base for this treatment and its adaptations. A solid
theoretical foundation allows for adequate evaluation of
content, structural, and developmental adaptations and Introduction
provides a framework for understanding which symptoms
or behaviors are expected to improve with treatment and Dialectical behavior therapy (DBT) is a cognitive behav-
why. We first summarize the adult DBT literature, ioral treatment originally developed by Linehan (1993a, b)
including theory, treatment structure and content, and for the treatment of chronically suicidal individuals, often
outcome research. Then, we review theoretical underpin- with borderline personality disorder (BPD). Positive results
nings, adaptations, and outcomes of DBT for adolescents. from randomized controlled trials (RCTs) with adults have
DBT has been adapted for adolescents with various psy- prompted researchers to adapt DBT for adolescents who
chiatric disorders (i.e., BPD, mood disorders, externalizing exhibit similar behavioral and emotional dysregulation.
disorders, eating disorders, trichotillomania) and problem Given this interest in DBT for adolescents, it is important
behaviors (i.e., suicide ideation and behavior, NSSI) across to review the theoretical rationale and the evidence base for
several settings (i.e., outpatient, day program, inpatient, this treatment and its adaptations. A solid theoretical
residential, correctional facility). The rationale for using foundation allows for adequate evaluation of content,
DBT with these adolescents rests in the common under- structural, and developmental adaptations and provides a
lying dysfunction in emotion regulation among the framework for understanding which symptoms or behav-
iors are expected to improve with treatment and why. We
first summarize the adult DBT literature, including theory,
H. A. MacPherson (&) M. A. Fristad
Department of Psychiatry, The Ohio State University, 1670 treatment structure and content, and outcome research.
Upham Drive, Suite 460, Columbus, OH 43210-1250, USA Then, we review theoretical underpinnings, adaptations,
e-mail: [email protected] and empirical outcomes of DBT for adolescents. Regarding
the outcome literature of DBT for adolescents, studies of
H. A. MacPherson J. S. Cheavens M. A. Fristad
Department of Psychology, The Ohio State University, youth with BPD features, suicide ideation, suicide behav-
1835 Neil Avenue, Columbus, OH 43210-1250, USA ior, and/or non-suicidal self-injury (NSSI) are reviewed in
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60 Clin Child Fam Psychol Rev (2013) 16:59–80
Table 1; studies of youth with oppositional defiant disorder highlighting and accepting this tension can help both thera-
(ODD), bipolar disorder (BD), binge eating disorder pist and client move past a treatment standstill and foster
(BED), anorexia nervosa (AN), bulimia nervosa (BN), and change (Rizvi et al. 2012). The central dialectic in DBT is the
trichotillomania (TTM) are reviewed in Table 2; and intrinsic tension between acceptance and change (Linehan
studies that investigated DBT for adolescents in diverse 1997). For a review of dialectics in DBT, see Fruzzetti and
settings (i.e., correctional facilities, residential treatment Fruzzetti (2008).
centers, long-term inpatient units, day treatment programs) DBT is a theoretically derived treatment in which skills
are reviewed in Table 3. We conclude with a discussion of and therapeutic techniques were developed to target spe-
limitations in the adolescent DBT literature and also offer cific deficits outlined in Linehan’s (1993a) biosocial theory
considerations for future research. Review of research of BPD. The biosocial theory suggests that BPD is pri-
efforts suggests DBT may be beneficial for adolescents marily a dysfunction of emotion regulation (Linehan
with a broad array of emotion regulation difficulties, par- 1993a), or the ability to monitor, evaluate, and modulate
ticularly underregulation of emotion resulting in behavioral one’s affective state (i.e., when and what emotions occur,
excess. However, RCTs are needed to provide more and how one experiences and expresses those emotions) in
definitive evidence for the efficacy of DBT for adolescents. order to accomplish one’s goals (Gross 1998; Thompson
1994). Specifically, the biosocial theory posits that
the emotional, behavioral, interpersonal, cognitive, and
Dialectical Behavior Therapy for Adults selfdysregulation of individuals with BPD are developed
and maintained through transaction between a biological
DBT incorporates aspects of behavioral science, dialectical tendency toward emotion dysregulation and an invalidating
philosophy, and Zen practice. Through a balance of change environment. An early biological vulnerability, expressed
and acceptance techniques within in a dialectical frame- in childhood as impulsivity, has also been identified as a
work, DBT aims to extinguish maladaptive behaviors and precursor to the development of BPD (Crowell et al. 2009).
shape and reinforce adaptive behaviors within a validating Emotion dysregulation stems in part from emotional vul-
environment, with the goal of helping clients build a life nerability, resulting in frequent and intense emotional
worth living. The following overview first discusses dia- experiences, combined with an inability to adequately
lectical and biosocial theoretical underpinnings of DBT regulate emotions. Characteristics of emotional vulnera-
and treatment components, modes, and strategies, as bility include high sensitivity to emotional stimuli, emo-
delineated in the individual therapy and skills training tional intensity, and slow return to emotional baseline.
manuals by Linehan (1993a, b). This section concludes An invalidating environment negates, punishes, and/or
with a summary of the adult DBT outcome literature. responds erratically and inappropriately to private experi-
ences, punishes emotional displays and intermittently
Theory reinforces emotional escalation, and oversimplifies the ease
of problem solving. Invalidation has also been associated
Both dialectical philosophy and the biosocial theory underlie with increased levels of negative affect and physiological
the DBT framework. Dialectical philosophy posits a arousal (Shenk and Fruzzetti 2011). As a result, emotion-
worldview emphasizing wholeness, interrelatedness, and ally vulnerable individuals who experience invalidating
process. It also suggests that there is no absolute truth and environments have never learned how to label and regulate
instead emphasizes the existence of opposing forces simul- emotions, how to tolerate distress, or when to trust their
taneously (i.e., thesis and antithesis). Dialectical change or emotional responses. They tend to invalidate their emo-
progress comes from the resolution of opposing forces, tional experiences, look to others for accurate reflections of
through the recognition of the truth or validity in each pole, reality, and oversimplify the ease of problem solving. From
into a synthesis. Regarding therapeutic dialog and relation- a biosocial perspective, BPD behaviors resulting from the
ship, dialectics refer to change by persuasion, making use of transaction between emotional vulnerability and an inval-
oppositions inherent in the therapeutic relationship, and idating environment function to regulate emotions or are
continually questioning what is being left out of under- consequences of failed emotion regulation. Recent empir-
standing, to reduce polarized thoughts and behaviors. In ical research supports the central role of emotion dysreg-
DBT, dialectics inform a worldview and communication ulation not only in BPD (Chapman et al. 2008; Glenn and
strategies used to elicit change (e.g., by the therapist high- Klonsky 2009; Gratz et al. 2006; Hughes et al. 2012;
lighting opposing viewpoints and simultaneously looking for Putnam and Silk 2005; Reeves et al. 2010; Selby and Joiner
truth in each perspective). DBT assumes opposing views can 2009) but also across broad areas of psychopathology
exist within a person at the same time (e.g., desire to live and (Aldao et al. 2010; Kring and Sloan 2010; Nolen-Hoek-
desire to die), which can result in conflict; however, sema 2012).
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Clin Child Fam Psychol Rev (2013) 16:59–80 61
Table 1 Studies of dialectical behavior therapy for adolescents with borderline personality disorder symptoms, suicide ideation, suicide
behavior, and/or non-suicidal self-injury
Authors Design/Setting N, % Female Age M or Inclusion Criteria % Completed DBT Format Outcomes
Range
Miller et al. Pre–post 33 14–19 Self-injury in past N/A (only 12 weeks: weekly Significant posttreatment
(2000) Outpatient 85 % F of 27 16 weeks or examined individual therapy and improvement in BPD
youth with current suicide treatment multifamily skills group, symptoms; all skills rated
complete ideation; 3 BPD completers) telephone coaching, moderately to extremely
data symptoms consultation team helpful; distress tolerance
(self-soothe) and
mindfulness skills (do
what works, stay focused)
rated most helpful
Woodberry Pre–post 46 13–18 History of suicide 63 % 15 weeks: weekly Significant posttreatment
and Community 89 % F attempts, self- individual therapy and improvements in
Popenoe clinic injury, and/or multifamily skills group, depression (d = 0.76 to
(2008) unstable affect telephone coaching, 0.84), anger (d = 0.94),
or relationships consultation team dissociation (d = 0.69),
in past overall psychiatric
3–6 months symptoms and functional
difficulties (d = 0.63),
suicide ideation
(d = 0.73), thoughts of
NSSI (d = 0.62), parent
report of own depression
(d = 0.72); nonsignificant
improvements in
internalizing (d = 0.55),
externalizing (d = 0.60),
total problems (d = 0.65)
James et al. Pre–post with 16 15–18 History of 87.5 % 1 year (2 6-month blocks): Significant posttreatment
(2008) follow-up 100 % F [6 months of weekly individual improvements in
Community severe and therapy and adolescent depression, hopelessness,
clinic persistent skills group, telephone NSSI, general
deliberate self- coaching functioning; gains
harm (all maintained at 8-month
had C 5 BPD follow-up
symptoms)
James et al. Pre–post 25 13–17 History of 72 % 1 year (2 6-month blocks): Significant posttreatment
(2011) Community 88 % F [6 months of weekly individual improvements in
clinic severe and therapy and adolescent depression, hopelessness,
persistent skills group, telephone NSSI, general
deliberate self- coaching, consultation functioning; findings
harm (all team, outreach strategies maintained with intent-to-
had C 5 BPD (e.g., meals, treat analyses
symptoms) transportation, caregiver
consultation)
Fleischhaker Pre–post with 12 13–19 NSSI or suicide 75 % 16–24 weeks: weekly Significant improvements at
et al. follow-up 100 % F behavior in past individual therapy and 1-year follow-up in
(2011) Outpatient 16 weeks; BPD multifamily skills group, suicide behavior (8 youth
diagnosis or C3 telephone coaching, attempted pretreatment;
BPD symptoms consultation team no attempts during study
or follow-up), NSSI
(d = 0.92), psychosocial
adjustment (d = 1.30 to
3.40 for significant
improvements),
psychopathology
(d = 0.54 to 2.14 for
significant
improvements), BPD
symptoms (pretreatment
M = 5.8, SD = 1.3;
follow-up M = 2.75,
SD = 1.9)
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Table 1 continued
Authors Design/Setting N, % Female Age M or Inclusion Criteria % Completed DBT Format Outcomes
Range
Rathus and Quasi- DBT = 29 DBT = 16.1 Suicide attempt DBT = 62 % 12 weeks: Posttreatment, DBT
Miller experimental TAU = 82 TAU = 15.0 in last TAU = 40 % DBT = weekly individual adolescents demonstrated
(2002) Outpatient 16 weeks or therapy and multifamily significantly fewer
93 % F in current suicide psychiatric
DBT skills group, telephone
ideation; BPD coaching, consultation hospitalizations (0 %
73 % F in diagnosis team versus 13 %) and higher
TAU or C 3 BPD treatment completion
symptoms TAU = weekly individual compared with TAU; 1
psychodynamic suicide attempt in DBT
psychotherapy and versus 7 in TAU; DBT
family therapy adolescents demonstrated
significant reductions in
suicide ideation,
depression, anxiety,
general psychiatric
symptoms, global
severity, BPD symptoms
posttreatment (not
measured in or compared
with TAU)
Katz et al. Quasi- DBT = 32 14–17 Recent suicide N/A 2 weeks: Posttreatment, DBT
(2004) experimental TAU = 30 attempt or (treatment DBT = 4 individual adolescents demonstrated
with follow- suicide completion therapy sessions, 10 significant reduction in
up 84 % F in ideation; required) number of violent
total adolescent skills group
Inpatient agreement to sessions, consultation incidents on unit
sample stay in hospital compared with TAU;
team, DBT milieu
for the duration significant reduction in
of treatment TAU = C1 per week total number of violent
individual and daily incidents on unit
group psychodynamic comparing 6-months
psychotherapy, case before and after DBT;
management, both groups demonstrated
psychodynamic milieu significant reductions in
NSSI (DBT d = 0.63;
TAU d = 0.73),
depression (DBT
d = 1.67; TAU
d = 1.05), suicide
ideation (DBT d = 2.12;
TAU d = 1.36) over
1-year follow-up
DBT dialectical behavior therapy, F female, BPD borderline personality disorder, N/A not applicable, NSSI non-suicidal self-injury, TAU treatment as usual
Using dialectical philosophy and biosocial theory, experience life as a series of extreme problems contrasted
Linehan (1993a) described common dialectical dilemmas with an inability to experience emotions associated with
of individuals with BPD, characterized as six classes of trauma or loss. Individuals with BPD are likely to vacillate
behaviors that represent the extremes of three continua. At between these polarities, causing distress (Linehan and
one end of each continuum is a class of behaviors Schmidt 1995). In line with dialectical philosophy, the
hypothesized to be biologically driven, and at the other end overarching target of treatment is to help patients find the
is a class of behaviors thought to be socially determined truth in each end of the dialectic and create a synthesis that
and maintained. The first dialectical dilemma, emotional reduces the distress associated with extreme vacillation.
vulnerability versus self-invalidation, is a tendency to
vacillate between intense, uncontrollable emotional suf- Treatment Functions, Modes, and Strategies
fering and dismissal, judgment, and invalidation of suf-
fering. Active passivity versus apparent competence, the Dialectical philosophy and biosocial theory inform DBT
second dialectical dilemma, involves passivity in solving functions, structure, and strategies. DBT has five functions:
one’s problems while actively engaging others to solve enhancing behavioral capabilities; improving motivation;
problems, coupled with the tendency of others to overes- assuring generalization of gains to the natural environment;
timate the capabilities of the individual with BPD. Lastly, structuring the environment so it reinforces functional
unrelenting crises versus inhibited grieving is a tendency to rather than dysfunctional behaviors; and enhancing
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Table 2 Studies of dialectical behavior therapy for adolescents with oppositional defiant disorder, bipolar disorder, eating disorders, and
trichotillomania
Authors Design/ N, % Female Age Inclusion Criteria % DBT Format Outcomes
Setting or Completed
Range
Nelson- Pre–post 54 10–15 Oppositional 69 % 16 weeks: weekly Significant posttreatment

Gray Outpatient 15 % F of defiant disorder (5 youth adolescent skills group improvements in
et al. 32 youth diagnosis repeated) with adaptations to positive behaviors (i.e.,
(2006) who improve attendance and interpersonal strength),
completed homework completion oppositional defiant
treatment (e.g., pizza, financial disorder and
incentives) externalizing behaviors,
depressive symptoms,
internalizing symptoms,
total problem behaviors
Goldstein Pre–post 10 14–18 Bipolar I, II, or 90 % 1 year: 24 weekly then 12 High satisfaction and
et al. Specialty 80 % F NOS diagnosis monthly sessions significant posttreatment
(2007) outpatient with acute alternating individual improvements in suicide
clinic manic, mixed, or therapy with individual ideation (d = 0.9 and
depressive family skills training, 1.2), emotion
episode in last telephone coaching, BD dysregulation (d = 0.3),
3 months adaptations (e.g., BD depression (d = 0.7);
psychoeducation) nonsignificant
improvement in NSSI
(d = 0.8)
Safer Case study 1F 16 Binge eating 100 % 21 weeks: weekly Reduced frequency and
et al. with disorder individual therapy with severity of binge
(2007) follow-up diagnosis skills, diary card, chain episodes posttreatment
Specialty analyses review, 4 family and at 3-month follow-
outpatient sessions, telephone up
clinic coaching, ED adaptations
(e.g., DBT model of EDs)
Salbach- Case series AN = 6 12–18 Anorexia nervosa 92 % 25 weeks: weekly Significant posttreatment
Andrae Outpatient BN = 6 or bulimia individual therapy and improvements in
et al. nervosa adolescent skills group (8 restricting (d = 1.2),
100 % F
(2008) diagnosis multifamily groups), bingeing (d = 1.9),
telephone coaching, purging (d = 1.7),
consultation team, ED general psychopathology
adaptations (e.g., review (d = 0.43 to 1.10); AN
nutrition, body image) adolescents
demonstrated significant
improvement in body
mass index (d = -2.6)
Welch Case study 1F 16 Trichotillomania 100 % 16 weeks: weekly Improvements in hair
and Kim with diagnosis individual therapy with pulling, emotion
(2012) follow-up skills and chain analyses regulation, anxiety,
Outpatient review, parent check-in depression
meetings, TTM posttreatment; slight
adaptations (e.g., TTM worsening of hair pulling
psychoeducation, habit from posttreatment to
reversal, stimulus control) follow-up
DBT dialectical behavior therapy, F female, NOS not otherwise specified, BD bipolar disorder, NSSI non-suicidal self-injury, ED eating disorder,
AN anorexia nervosa, BN bulimia nervosa, TTM trichotillomania
therapist capabilities and motivation. These functions are one, the therapist helps the client attain basic capabilities
apparent over the course of four stages of treatment, each (i.e., adding to the skill repertoire) by reducing life-
with a hierarchy of treatment targets, and four modes of threatening behaviors (e.g., suicide behavior, self-injury),
therapy. In the pretreatment stage, the therapist orients the therapy-interfering behaviors (e.g., noncompliance, nonat-
individual to treatment and obtains commitment to the tendance), and quality-of-life-interfering behaviors (e.g.,
therapist–client relationship and to work on goals. In stage homelessness, psychiatric disorders), and by increasing
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Table 3 Studies of dialectical behavior therapy for adolescents in diverse settings

Authors Design/ N, % Female Age M or Inclusion Criteria % Completed DBT Format Outcomes
Setting Range
Trupin Pre–post DBT = 45 Mental health Incarcerated N/A 10 months: Mental health unit
et al. with TAU = 45 unit = 14.8 females on DBT ? TAU = 1–2 adolescents showed
(2002) control General mental health times/week adolescent significant reduction in
100 % F
group population unit (DBT skills group behavior problems
Juvenile unit = 15.5 n = 22) or (aggression, NSSI,
TAU = educational,
detention general classroom disruption);
TAU = 15.2 recreational,
facility population unit staff on mental health
vocational programs,
(DBT n = 23; unit (who received
group meetings,
TAU n = 45) more DBT training; 80
behavior modification
versus 16 h) showed
significant reduction in
punitive responses
compared to year prior;
no behavior or staff
changes on other units
Shelton Pre–post 38 16–19 Incarcerated 68 % 16 weeks: weekly Significant posttreatment
et al. secondary 0%F males with adolescent skills group improvements in
(2011) analyses impulsive coping, aggression
Correctional behavior impulsive behaviors;
facility problems nonsignificant
improvements in
negative affect, self-
control
Sunseri Pre–post 68 (n = 42 12–18 Resident at N/A 29 months: weekly After DBT
(2004) compared before DBT; treatment individual therapy, implementation,
29 months n = 26 after facility; twice weekly significant reductions
before and DBT) commitment to adolescent skills in premature
after DBT 100 % F DBT group, telephone terminations due to
Residential coaching, consultation self-harm or
treatment team psychiatric
facility hospitalization (16.7 %
versus 0 %), number of
days spent in
psychiatric hospitals
due to NSSI (71 days
from 8 youth versus
42 days from 6 youth),
duration of physical
restraints and
seclusions (median of
20 min versus 11 min)
Wasser Pre–post DBT = 12 DBT = 14.7 Resident at N/A (selected youth 17 weeks: General psychiatric
et al. with STM = 12 STM = 14.6 treatment who already DBT = weekly symptoms improved
(2008) control facility completed DBT) individual therapy and posttreatment for both
25 % F
group multifamily skills groups; DBT
(matched) group adolescents had
Residential STM = family, group, significantly greater
treatment individual, behavioral, reduction in
facility medication treatment depression; STM
adolescents had
significantly greater
reduction in
psychomotor
excitation
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Table 3 continued
Authors Design/ N, % Female Age M or Inclusion Criteria % Completed DBT Format Outcomes
Setting Range
McDonell Pre–post DBT = 106 12–17 Admitted to N/A 1 year: 3 DBT intensity DBT adolescents
et al. with (from 2000 to inpatient unit levels (unknown demonstrated
(2010) historical 2005) frequency) = DBT significant
control Control = 104 milieu (chain analyses, improvement in global
group (from 1995 to behavior interventions, functioning and
Long-term 1999) individual skills); DBT significant reduction in
inpatient milieu ? adolescent number of
58 % F
unit skills group; DBT medications; compared
milieu ? adolescent with control, DBT
skills group ? adolescents
individual therapy; all demonstrated
with consultation team significant reduction in
Control = individual NSSI
and family therapy as
needed
Charlton Pre–post 19 Unknown Enrolled in day 52 % moved to less 19 months: weekly Adolescents
and Day treatment restrictive setting; individual therapy, demonstrated
Dykstra treatment program for 16 % remained in twice weekly increased DBT skills
(2011) program developmental day program; 19 % multifamily skills use, ability to identify
and behavioral moved to more group (when family maladaptive emotions,
health needs restrictive setting; available), telephone thoughts, actions;
16 % lost to coaching, consultation significant correlation
follow-up team, adaptations for between problem
intellectual disabilities behaviors (e.g., argued,
(e.g., concrete and tried to avoid work,
simplified language tried to hurt self or
and handouts) others, attempted
suicide), negative
thoughts, negative
feelings with month
(i.e., as number of
months in program
increased number of
problem behaviors,
negative thoughts,
negative feelings
decreased)
DBT dialectical behavior therapy, TAU treatment as usual, F female, N/A not applicable, NSSI non-suicidal self-injury, STM standard therapeutic milieu
behavioral skills. In stage two, the therapist helps the client therapy; weekly group skills training; as-needed telephone
replace quiet desperation with normative emotional expe- coaching; and weekly therapist consultation team meetings
riencing by decreasing posttraumatic stress. In stage three, (Robins and Rosenthal 2011). The individual therapist is
the therapist helps the client achieve ordinary happiness responsible for addressing motivational problems, treat-
and unhappiness and resolve problems in living by ment planning, working on progress toward goals, and
increasing respect for self and achieving individual goals. assessing and problem-solving crises and skill deficits.
Finally, in stage four, the therapist helps the client resolve a Other modes of treatment revolve around the individual
sense of incompleteness and attain the capacity for freedom therapy (Linehan 1993a). Individual therapy is organized
and sustained contentment. Most of the empirical research around and sequentially targets the aforementioned hier-
on DBT has focused on stage one targets; however, flexi- archy of behaviors occurring either in session or reported
bility offered by the DBT stages allows for the application on the client’s weekly diary card, a monitoring tool on
of DBT to individuals with varying degrees of dysfunction which clients record daily ratings of emotions, problem
(Lynch et al. 2007b). behaviors, and skills use (Rizvi et al. 2012). For example, a
Aforementioned functions and stages of treatment are therapist treating a client in stage one would first address
accomplished via four modes of therapy: weekly individual suicide or self-injurious behavior, followed by any forms of
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noncompliance or behaviors interfering with treatment, Lastly, weekly therapist consultation team meetings
followed by Axis I disorders or other life problems, and (1–2 h) hold therapists within the therapeutic frame, bal-
finally followed by skill building. Strategies for addressing ance therapists’ interactions with clients, address problems
problem behaviors are described below. that arise in treatment, increase adherence to DBT princi-
Clients also participate in weekly group skills training. ples, and increase therapists’ motivation and capabilities in
Groups are conducted with a primary and coleader and range delivering DBT. During consultation team, mindfulness is
from 2 to 2.5 h, with the first half devoted to homework first practiced and then an agenda is set according to the
review and the second half spent teaching new skills (i.e., aforementioned target hierarchy and therapists’ needs (i.e.,
mindfulness, distress tolerance, emotion regulation, inter- help with individual clients or support when feeling burned
personal effectiveness). Mindfulness involves finding the out). Together, these treatment modalities (i.e., individual
synthesis between extremes by orienting to the truth in each therapy, group skills training, telephone coaching, consul-
position. These skills also include focusing attention by tation team meetings) aim to reduce clients’ dysfunctional
observing, describing, and participating in the present behaviors in the presence of dysregulated emotion.
moment without trying to change one’s present experience Finally, specific treatment strategies are used within the
and while assuming a nonjudgmental stance, focusing four modes of treatment to achieve the functions and tar-
awareness on one thing at a time, and developing effective- gets outlined in DBT (Robins and Rosenthal 2011). Dia-
ness (i.e., doing what is needed to achieve one’s goals). lectical strategies foster change by highlighting opposing
Mindfulness skills are central to DBT and thus are woven viewpoints and simultaneously looking for truth in each
throughout the other skills modules. Distress tolerance tea- perspective. A dialectical therapeutic relationship is con-
ches impulse control, distracting, and self-soothing strate- stantly balancing acceptance and change, flexibility and
gies for tolerating aversive contexts, surviving crises, and stability, nurturing and challenging, and a focus on capa-
radically accepting situations that cannot be changed without bilities and deficits, with the goal of achieving syntheses.
resorting to dysfunctional behavior. Emotion regulation Dialectical strategies also target behavioral extremes and
teaches methods for identifying and describing emotions, rigidity and highlight contradictions in the client’s thoughts
determining whether an emotion is justified by current cir- or behavior by offering alternative viewpoints, encouraging
cumstances, modulating emotions via acting opposite to the synthesis between opposing perspectives, and promoting
emotion or problem solving, reducing vulnerability to dialectical thinking and acting. Validation strategies
unwanted negative emotions, and increasing experience of involve the therapist’s acceptance of the client and serve to
positive emotions. Finally, interpersonal effectiveness tea- communicate to the client that his or her responses make
ches assertiveness skills aimed to help clients achieve their sense within the current context or are what would be
objectives in interpersonal interactions while also main- expected of almost anyone in a given situation (Linehan
taining positive relationships and their self-respect. These 1997). Stylistic strategies refer to style and form of thera-
skills are taught over 6 months and then repeated. Following pist interaction and include both reciprocal (e.g., responsive,
the treatment hierarchy, group skills training targets: ther- genuine) and irreverent (e.g., matter-of-fact, unexpected)
apy-destroying behaviors; skills acquisition, strengthening, communication. Together, dialectical and stylistic strategies
and generalization; and therapy-interfering behaviors. produce the movement, speed, and flow characteristic of
Clients are encouraged to use as-needed telephone therapist–client interactions in DBT.
coaching calls if they are experiencing suicide or self- Problem-solving strategies are the primary change
injurious urges, if they need help utilizing a skill or do not strategies in DBT and involve first understanding and
know what skill to use, or if there is a rupture in the labeling a selected problem behavior (e.g., suicide behav-
therapeutic relationship. These calls are typically of short iors, self-injury) via a behavioral chain analysis that iden-
duration (5–15 min) and consist of the therapist quickly tifies vulnerabilities, events, thoughts, feelings, sensations,
assessing the client’s problem and helping to identify the and behaviors that led up to the problem behavior, as well
most effective skill to use in the current situation. How- as consequences of the behavior. Subsequently, a solution
ever, clients are prohibited from calling the therapist within analysis is conducted to identify points of intervention that
24 h of suicide or self-injurious behaviors in order to avoid would disrupt the chain of events and prevent the problem
inadvertent reinforcement via therapist attention and behavior from recurring, with emphasis on rehearsal and
because the client has already used a strategy to relieve troubleshooting. DBT has four sets of change procedures:
distress (albeit maladaptive) instead of seeking assistance skills training, contingency management, exposure strate-
from the therapist in identifying an adaptive skill. Clients gies, and cognitive modification. Skills training teaches the
may call during this 24-h period to receive coaching for client new skills. Contingency management provides a
medical attention and/or if the client is having urges to self- consequence that influences the probability of a client’s
harm again. behavior occurring again. Exposure provides non-
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reinforced exposure to cues associated previously, but not DBT for adults with BPD has also been evaluated
currently, with a threat. Cognitive modification changes the adjunctive to medication (Linehan et al. 2008; Simpson
client’s dysfunctional assumptions or beliefs. Finally, when et al. 2004; Soler et al. 2005). Though these studies were
problems in the client’s environment interfere with func- RCTs, all participants received DBT and only the medi-
tioning or progress, the therapist employs case manage- cation condition (active medication versus placebo) dif-
ment strategies by either consulting with the client on how fered between groups.
to interact effectively with the environment or intervening Nine additional RCTs evaluated adapted DBT for adults
directly when the environmental contingencies are very with depression, eating disorders (EDs), attention-deficit/
powerful. Collectively, these treatment functions, modes, hyperactivity disorder (ADHD), and BD. Rationale for use
and strategies aim to reduce problematic behaviors asso- of DBT with these disorders rests in the common under-
ciated with dysregulated emotions while shaping and lying dysfunction in emotion regulation (Kring and Sloan
reinforcing more effective, adaptive behaviors. For a 2010). Two RCTs evaluated DBT plus antidepressant
review of DBT in clinical practice, see Dimeff and Koerner medication versus antidepressant medication alone for
(2007) and Rizvi et al. (2012). depressed older adults (Lynch et al. 2003) and depressed
older adults with at least one comorbid personality disorder
(Lynch et al. 2007a). DBT in these studies consisted of
Empirical Outcomes group skills training and telephone coaching (Lynch et al.
2003) or individual therapy and group skills training
Numerous randomized controlled trials (RCTs) with (Lynch et al. 2007a). One RCT for treatment-resistant
adults have demonstrated DBT’s efficacy in treating BPD depression evaluated DBT group skills training versus
and a range of other psychiatric disorders across various waitlist control (WLC; Harley et al. 2008). Two RCTs for
settings. Reviewed below are RCTs of DBT for adults, BED evaluated DBT group skills training versus WLC
empirical findings from these studies, and proposed (Telch et al. 2001) or an active group therapy comparison
mechanisms of change. To date, standard outpatient DBT (Safer et al. 2010). Two RCTs evaluated individual DBT
(including all four modes of therapy) for adults with BPD (with some skills training review) versus WLC for BN
has been evaluated in nine RCTs, three of which included (Safer et al. 2001) and binge eating and purging episodes
adults with BPD plus substance use disorders. Five RCTs (Hill et al. 2011). One RCT for ADHD evaluated DBT
compared DBT with treatment as usual (TAU; Carter group skills training versus structured group discussion
et al. 2010; Koons et al. 2001; Linehan et al. 1991, 1999; control (Hirvikoski et al. 2011). Lastly, one RCT for BD
Verheul et al. 2003), while four RCTs compared DBT evaluated DBT group skills training versus WLC (Van Dijk
with active treatments (Clarkin et al. 2007; Linehan et al. et al. 2012).
2002, 2006; McMain et al. 2009). Active comparison In addition to outpatient settings, where most of the
treatments included comprehensive validation with aforementioned RCTs were conducted, DBT has been
12-step (Linehan et al. 2002), community treatment by successfully implemented with adults in inpatient units
experts (primarily psychodynamic treatment; Linehan (e.g., Bohus et al. 2000, 2004; Kröger et al. 2006, 2010),
et al. 2006), transference-focused therapy or supportive community mental health centers (e.g., Comtois et al.
treatment (Clarkin et al. 2007), and general psychiatric 2007; Pasieczny and Connor 2011; Prendergast and
management (psychodynamic treatment plus medication McCausland 2007), and forensic settings (e.g., Berzins and
management; McMain et al. 2009). A recent meta-anal- Trestman 2004; Bradley and Follingstad 2003; Evershed
ysis including eight RCTs and eight non-RCTs also et al. 2003). However, these studies were not RCTs.
examined the efficacy of standard DBT for adults with Results from RCTs cumulatively suggest that partici-
BPD (Kliem et al. 2010). pation in DBT is associated with: reduced frequency and
Two recent RCTs of DBT utilized broader inclusion severity of suicide behavior and/or NSSI (Carter et al.
criteria than BPD diagnosis. One RCT evaluated DBT 2010; Clarkin et al. 2007; Feigenbaum et al. 2012; Koons
versus TAU in an outpatient publicly funded service setting et al. 2001; Linehan et al. 1991, 1993, 1999, 2006, 2008;
for adults with any cluster B personality disorder (i.e., McMain et al. 2009, 2012; Pistorello et al. 2012; van den
borderline, antisocial, narcissistic, histrionic; Feigenbaum Bosch et al. 2002, 2005; Verheul et al. 2003) and suicide
et al. 2012). The other RCT evaluated DBT versus opti- ideation (Koons et al. 2001; Linehan et al. 2006); decreased
mized TAU (supervision provided by non-cognitive BPD symptoms (McMain et al. 2009, 2012; Pistorello et al.
behavioral expert) in a college counseling center for stu- 2012), substance abuse/dependence (Harned et al. 2008;
dents who were suicidal, reported at least one lifetime Linehan et al. 1999, 2002; van den Bosch et al. 2005), ED
NSSI or suicide attempt, and endorsed three or more BPD symptoms (Hill et al. 2011; Safer et al. 2001, 2010; Telch
symptoms (Pistorello et al. 2012). et al. 2001), ADHD symptoms (Hirvikoski et al. 2011),
123
hopelessness (Koons et al. 2001), depression (Clarkin et al. Telch et al. 2001), ADHD (Hirvikoski et al. 2011), and BD
2007; Feigenbaum et al. 2012; Harley et al. 2008; Koons (Van Dijk et al. 2012). In addition, a recent examination of
et al. 2001; Linehan et al. 2006, 2008; Lynch et al. 2003, mediators in three RCTs of DBT for BPD revealed that
2007a; McMain et al. 2009, 2012; Pistorello et al. 2012; DBT skills fully mediated the decrease in suicide attempts
Simpson et al. 2004; Soler et al. 2005; Van Dijk et al. and depression and the increase in control of anger over
2012), anger/irritability (Feigenbaum et al. 2012; Koons time (Neacsiu et al. 2010). DBT skills also partially med-
et al. 2001; Linehan et al. 1993, 1994, 1999, 2008; McMain iated the decrease in NSSI over time. Efficacy of DBT
et al. 2009, 2012), aggression (Linehan et al. 2008; Soler group skills training in aforementioned studies supports a
et al. 2005), and affective control (Van Dijk et al. 2012); skills deficit model of these psychiatric disorders.
reduced health service utilization and/or inpatient psychi- However, some RCTs that evaluated adapted DBT for
atric days (Carter et al. 2010; Koons et al. 2001; Linehan other psychiatric disorders found support for individual
et al. 1991, 1993, 2006; McMain et al. 2009, 2012; Van therapy alone (with some skills training review) among
Dijk et al. 2012); and improved social and global adjust- adults with BN (Safer et al. 2001) and binge eating and
ment (Clarkin et al. 2007; Feigenbaum et al. 2012; Linehan purging episodes (Hill et al. 2011). In addition, a recent
et al. 1993, 1994, 1999; Pistorello et al. 2012; Simpson non-RCT found similar positive outcomes among adults
et al. 2004), treatment retention (Linehan et al. 1991, 1999, with BPD who received 1 year of standard DBT versus
2006; Safer et al. 2010; van den Bosch et al. 2002; Verheul individual DBT (with incorporated skills training; Andión
et al. 2003), quality of life (Carter et al. 2010; McMain et al. 2012). The role of the therapeutic relationship in DBT
et al. 2009, 2012), and interpersonal functioning (McMain has recently been examined using data from a previous
et al. 2009, 2012). RCT (Linehan et al. 2006). Specifically, relative to com-
While all RCTs demonstrated DBT improved emotional munity treatment by experts, DBT participants developed
and behavioral symptoms following treatment, some significantly greater self-affirmation, self-love, self-pro-
studies conducted by researchers not affiliated with the tection, and less self-attack (Bedics et al. 2012a). In addi-
treatment developers (e.g., Carter et al. 2010; Feigenbaum tion, DBT participants who perceived their therapist as
et al. 2012) and studies that compared DBT with active affirming and protecting reported less frequent NSSI.
treatments (especially treatments specifically designed for Support has also been demonstrated for therapists’ bal-
individuals with BPD: Clarkin et al. 2007; McMain et al. ancing of autonomy and control, maintaining a non-
2009, 2012) did not always yield significant between-group pejorative stance, and using warmth and autonomy (Bedics
differences. Results from the meta-analysis of standard et al. 2012b). These studies support the importance of
DBT for adults with BPD by Kliem et al. (2010) also found individual therapy components in DBT (e.g., behavior
good treatment retention (27.3 % drop-out rate), a moder- therapy strategies, combination of acceptance and change
ate global effect size, and a moderate effect size for suicide interventions, dialectical strategies, nonjudgmental
and self-injurious behaviors. However, this effect size assumptions about patients) and the quality of the thera-
decreased to small when DBT was compared with BPD- peutic relationship in ensuring positive clinical outcomes.
specific treatments, and a small reduction in effects was Thus, while additional research is needed to examine the
shown at follow-ups. Thus, numerous studies of DBT for utility of specific treatment modes and strategies and their
BPD and other psychiatric disorders in various settings role in the efficacy of DBT, results from RCTs support the
have yielded positive results and suggest efficacy in use standard DBT for adults with BPD, with growing
improving various emotional and behavioral symptoms in evidence for adaptations of DBT for other psychiatric
adults, though not always to a significantly greater degree disorders.
than active treatments.
Though growing evidence supports the efficacy of DBT
for various adult psychiatric disorders, mechanisms of Dialectical Behavior Therapy for Adolescents
change and necessary components linked with clinical
improvements are not well understood (Robins and Chap- Given positive outcomes with adults, recent research has
man 2004). As aforementioned, most RCTs have evaluated adapted and evaluated DBT for adolescents. The follow-
the efficacy of standard DBT for BPD. However, a recent ing section reviews the theoretical underpinnings
RCT demonstrated efficacy of 3 months of DBT group informing use of DBT with adolescents, summarizes
skills training alone versus psychodynamic-oriented group treatment adaptations originally proposed by Miller et al.
skills training control among adults with BPD (Soler et al. (1997, 2007b), and concludes with a review of empirical
2009). Other RCTs have demonstrated efficacy of group studies of DBT for adolescents. Limitations of current
skills training alone among adults with depression (Harley studies and considerations for future research are also
et al. 2008; Lynch et al. 2003), BED (Safer et al. 2010; discussed.
123
Theory (Linehan 1993a). Given that adolescents can also present

with similar dysregulated emotions and problematic
As reviewed above, DBT has been found to be efficacious behaviors, and emotion dysregulation has been linked with
for adults with BPD (www.div12.org/Psychological the development of various forms of psychopathology in
Treatments/treatments/bpd_dbt.html). Thus, adaptation of adolescents (McLaughlin et al. 2011), extension of DBT to
DBT for adolescents with BPD symptoms or diagnosis may a broader group of adolescents (as opposed to just those
be warranted and beneficial. Though most evaluations of with BPD) may be warranted.
DBT for adolescents have included youth with BPD fea- All of the behaviors and disorders that have been tar-
tures, other studies have targeted youth with various psy- geted in studies of DBT for adolescents can be conceptu-
chiatric disorders (i.e., mood disorders, externalizing alized by poor emotion regulation. For example, all
disorders, EDs, TTM) and problem behaviors (i.e., suicide evaluations of adolescents with BPD features (Fleischhaker
ideation and behavior, NSSI) across several settings (i.e., et al. 2011; James et al. 2008, 2011; Miller et al. 2000;
outpatient, day program, inpatient, residential, correctional Rathus and Miller 2002; Woodberry and Popenoe 2008)
facility). The rationale for using DBT with these adoles- and one study of hospitalized adolescents (Katz et al. 2004)
cents rests in the common underlying dysfunction in also incorporated suicide ideation, suicide behavior, and/or
emotion regulation among the aforementioned disorders NSSI as study inclusion criteria. Indeed, suicide ideation
and problem behaviors. (Orbach et al. 2007), suicide behavior (Tamás et al. 2007;
Most adolescent DBT studies targeted youth with BPD Zlotnick et al. 1997), and NSSI (Adrian et al. 2011; Nock
features (Fleischhaker et al. 2011; James et al. 2008, 2011; and Prinstein 2004; Nock et al. 2009) have been shown to
Miller et al. 2000; Rathus and Miller 2002; Woodberry and be related to emotion dysregulation in youth. For example,
Popenoe 2008). Though somewhat controversial, research the most common self-reported reasons for adolescent
suggests that the prevalence, reliability, and validity of NSSI are automatic positive reinforcement (i.e., to create a
BPD diagnoses in adolescent samples are largely compa- desirable physiological state) and automatic negative
rable to those found among adult samples (Miller et al. reinforcement (i.e., to escape from an averse physiological
2008). Adolescents with BPD present with similar symp- state; Nock and Prinstein 2004; Nock et al. 2009). In
toms and functional impairment as adults with BPD addition, the automatic negative reinforcement function of
(Becker et al. 2002; Chanen et al. 2007). However, NSSI has been associated with a history of suicide attempts
research on the stability of BPD over time is mixed. While in adolescents (Nock and Prinstein 2005), thus supporting
for some severely affected adolescents the diagnosis of an emotion regulation function of suicide ideation, suicide
BPD remains stable over time, a less severe subgroup of behavior, and NSSI in adolescents.
youth moves in and out of diagnosis (Miller et al. 2008). Adaptations of DBT for youth with ODD (Nelson-Gray
These findings are consistent with research suggesting that et al. 2006), BD (Goldstein et al. 2007), BED (Safer et al.
BPD diagnostic status in adults is not particularly stable 2007), AN (Salbach-Andrae et al. 2008), BN (Salbach-
(Zanarini et al. 2010). Symptoms related to temperament, Andrae et al. 2008), and TTM (Welch and Kim 2012) can
such as abandonment fears, have higher positive predictive also be tied to a common underlying dysfunction in emo-
power when making the diagnosis of BPD in adolescents tion regulation. For example, the diagnostic criteria for
(Becker et al. 2002) and also endure longer than other BPD ODD include emotion dysregulation (e.g., often loses
symptoms (e.g., those related to impulsivity) in adult temper, spiteful and vindictive), interpersonal difficulties
samples (Zanarini et al. 2007). Thus, research indicates that (e.g., argues with adults, annoys others on purpose), and
the diagnosis of BPD in adolescents is comparable in terms poor distress tolerance (e.g., easily annoyed, angry and
of symptom constellation, functional impairment, and resentful; Nelson-Gray et al. 2006). In addition, early
temporal stability to the diagnosis when made in adult emotion dysregulation has been linked with the develop-
samples. Therefore, adaptation of DBT, an evidence-based ment of ODD (Stingaris et al. 2010), while recent research
treatment for adults with BPD, for adolescents who exhibit suggests that early ADHD and ODD symptoms predict
BPD features or diagnosis is a logical extension. subsequent development of BPD symptoms (Burke and
Although most empirical studies of DBT have included Stepp 2012; Stepp et al. 2012). Similarly, research posits
adults with BPD, DBT was originally developed to treat that the core feature of adolescent BD is emotion dysreg-
suicide-related behavior and extreme emotional and ulation (Carlson and Meyer 2006; Dickstein and Leibenluft
behavioral dysregulation (Robins and Rosenthal 2011). As 2006; Leibenluft et al. 2003). In addition, BD in adoles-
such, within the DBT framework, BPD is conceptualized cents is associated with suicide behavior (Goldstein et al.
primarily as a disorder of emotion regulation. Problematic 2005), NSSI (Esposito-Smythers et al. 2010), interpersonal
behaviors are viewed as efforts to regulate extreme emo- deficits (Goldstein et al. 2006), and treatment noncompli-
tions or consequences of failed emotion regulation ance (Coletti et al. 2005), all of which are DBT targets, and
123
DBT has been successfully implemented with adults with behavior, running away). Therefore, DBT in these settings
BD in a recent RCT with promising results (Van Dijk et al. is applied transdiagnostically with the aim of reducing the
2012). Thus, both ODD and BD in adolescents are asso- myriad symptoms related to behavioral and emotional
ciated with dysfunction in emotion regulation as well as dysregulation and that have demonstrated improvement in
other problem behaviors targeted in and responsive to adult RCTs of DBT.
DBT. Thus, DBT has been adapted for adolescents with BPD,
Emotion dysregulation has also been linked to EDs and suicide ideation and behavior, NSSI, ODD, BD, EDs, and
TTM. Regarding EDs, an adapted biosocial theory posits TTM. DBT has also been implemented in diverse settings
that EDs develop through transaction between an invali- with youth who present with varied psychiatric and
dating environment and a biological vulnerability to reg- behavioral impairment. Rationale for initiating DBT with
ulating emotions and/or to the hunger/satiety system these adolescents rests in the common problems in emotion
(Wisniewski and Kelly 2003; Wisniewski et al. 2007). ED regulation. Linehan (1993a) conceptualized BPD as a dis-
behaviors (bingeing, purging, restricting) are viewed as order of emotion regulation in the initial development of
behavioral attempts to avoid painful emotions, in the case the treatment, and as such, DBT is comprehensive and
of AN, or change painful emotions, in the case of BED and flexible in a way that allows for use with clients presenting
BN. Some empirical evidence also supports the role of with varied diagnoses, in diverse settings, across a rela-
emotion dysregulation in ED symptoms in youth (Sim and tively larger age range.
Zeman 2005). In addition, adolescents with EDs commonly
present with suicide ideation, suicide behavior, and NSSI, Treatment Adaptations
which are targets in DBT (Bjarehed and Lundh 2008;
Peebles et al. 2011; Ruuska et al. 2005). Also, DBT has Miller et al. (1997, 2007b) were the first to propose
been adapted for adults with EDs and demonstrated posi- adaptations of DBT for adolescents and subsequently
tive results in RCTs (Hill et al. 2011; Safer et al. 2001, developed a treatment manual. Their adaptations targeted
2010; Telch et al. 2001). Regarding TTM, research with youth exhibiting suicide ideation and behavior, NSSI, and
adults and youth indicates hair pulling is automatic/habit- BPD features. Subsequent adaptations for other adolescent
ual or functions to regulate emotions, with the latter cued presenting problems are modeled after and closely resem-
by negative emotions, intense thoughts or urges, or ble the Miller et al. (2007b) manual. DBT for adolescents
attempts to create symmetry (Christenson and Mackenzie generally follows the same format as standard DBT,
1994; Diefenbach et al. 2008; Flessner et al. 2007, 2008, including theoretical framework, functions, treatment tar-
2009; Shusterman et al. 2009). Also, DBT has been gets, treatment modes, and strategies (Klein and Miller
adapted for adults with TTM and demonstrated promising 2011). However, Miller et al. (2007b) introduced modifi-
results in a case study (Keuthen and Spirch 2012) and open cations to make DBT more developmentally appropriate
trial (Keuthen et al. 2010, 2011). Thus, EDs and TTM in for adolescents and their families. The following summary
adolescents are associated with emotion dysregulation and provides an overview of the adaptations to DBT for ado-
problem behaviors targeted in DBT, and studies of DBT for lescents, as delineated in the DBT manual for suicidal
adults with EDs and TTM demonstrated positive findings. adolescents by Miller et al. (2007b).
Some researchers have investigated DBT for adoles- DBT for adolescents includes seven main adaptations of
cents in particular settings with a transdiagnostic focus standard DBT. First, family members, usually parents, are
rather than targeting certain psychiatric disorders or included in multifamily skills training groups to enhance
behavioral problems. Specifically, DBT has been imple- generalization and reinforcement of skills and structure
mented with youth in correctional facilities (Shelton et al. adolescents’ environments (Miller et al. 2007a). In this
2011; Trupin et al. 2002), residential treatment facilities way, parents can serve as models and coaches for their
(Sunseri 2004; Wasser et al. 2008), long-term inpatient adolescents by utilizing and implementing skills. Parental
units (McDonell et al. 2010), and day treatment programs participation in skills training is designed to provide a
(Charlton and Dykstra 2011). Again, rationale for using common vocabulary for therapeutic techniques within
DBT with these adolescents is based on the underlying families and enhance parents’ ability to provide validation,
dysfunction in behavioral and emotional regulation. Youth support, and effective parenting. Including family members
who participated in DBT in aforementioned studies pre- in skills groups also offers the added benefits of providing
sented with a number of psychiatric diagnoses (e.g., BPD, in vivo opportunities to role play skills, fostering inter-
substance abuse/dependence, EDs, mood disorders, post- family support, reducing adolescents’ disruptive behaviors
traumatic stress disorder, ADHD, ODD, conduct disorder) in group, and enhancing treatment compliance. Family
and impairing behaviors (e.g., suicide ideation and members may also receive telephone coaching and con-
behavior, NSSI, aggression, impulsivity, disruptive sultation from the skills group therapist for skills
123
generalization, while adolescents receive telephone Fourth, the treatment length was reduced from 1 year to
coaching from the primary individual therapist (Steinberg 16 weeks. This may be the biggest change from standard
et al. 2011). DBT because the time in treatment is significantly reduced
Second, family therapy sessions are conducted on an but the content (e.g., dialectical dilemmas, skills training
as-needed basis. Although individual sessions with sig- modules) is increased. According to Miller et al. (2007b),
nificant others are incorporated into standard DBT for treatment length was modified so it would be more
adults, adapted DBT for adolescents focuses more appealing to adolescents, given that suicidal adolescents
explicitly on this mode of treatment (Miller et al. 2002; tend to complete only a limited number of therapy sessions.
Woodberry et al. 2002). Family therapy sessions were For example, up to 77 % of adolescents who attempt sui-
added because much of the turmoil in the lives of suicidal cide do not attend therapy appointments or fail to complete
adolescents involves their primary support system. Family treatment (Trautman et al. 1993). Also, Miller et al.
sessions are conducted when the relationship with a (2007b) aimed to offer a brief treatment because they were
family member is a central source of conflict or when a including many clients with first-time NSSI or suicide
crisis erupts within the family. The therapist may also attempts, many of whom did not meet full criteria for BPD.
initiate family sessions if the treatment would be Thus, they believed they could treat many of these ado-
enhanced by educating family members about particular lescents with a short-term treatment and offer optional
skills or aspects of treatment or if contingencies in the additional therapy (i.e., a graduate group or repeat of first
home are too powerful for the adolescent to ignore and phase of treatment) for those who continued to exhibit
continue to reinforce dysfunctional behavior. Goals of behavioral dyscontrol. Treatment length was also reduced
family sessions include preparing the adolescent for for pragmatic concerns so that clients who could not afford
family interactions, increasing parental understanding of extended therapy could still receive meaningful treatment,
adolescent’s emotional vulnerability, addressing parents’ which was in line with the current healthcare climate (e.g.,
own emotion dysregulation, improving familial commu- acceptable to insurance companies).
nication, modifying contingencies in the familial envi- A fifth adaptation, also involving the structure of DBT,
ronment, and crisis management. Typically, selected is a second phase of treatment: a 16 week optional graduate
family members will attend 3 to 4 sessions out of the group (with other treatment modes utilized as needed) for
adolescent’s 16 weeks of individual therapy, though more clients who continue to exhibit difficulties following the
or fewer sessions can be scheduled as needed. first phase of therapy (Miller et al. 2007a). Youth may
A third adaptation involves the development and repeat the graduate group as many times as necessary in
teaching of three adolescent–family dialectical dilemmas order to achieve their identified goals. Both phases of
(Rathus and Miller 2000). Similar to the original dialectical treatment address only the DBT stage one targets of
dilemmas proposed by Linehan (1993a), these adolescent– reducing life-threatening behaviors, reducing therapy-
family dialectical dilemmas are considered secondary interfering behaviors, reducing quality-of-life-interfering
behavioral targets in DBT. The first dialectical dilemma, behaviors, and increasing behavioral skills. The graduate
excessive leniency versus authoritarian control, involves group is designed to address the DBT treatment functions
placing too few behavioral demands or limits on the ado- of improving capabilities, improving motivation, and pro-
lescent, or being excessively permissive, versus enacting moting generalization of skills, but in a way that requires
coercive parenting methods limiting freedom, autonomy, less intensive adolescent participation and fewer program
and independence. Normalizing pathological behaviors resources. The goal of the graduate group is to reinforce
versus pathologizing normative behaviors, the second and generalize skills previously taught. Group sessions
dialectical dilemma, involves viewing developmentally involve adolescents reviewing and teaching skills to peers
normal adolescent behaviors as deviant versus failing to and consulting and problem solving with group members to
address or perceive deviant adolescent behaviors as such. foster peer coaching and support rather than reliance on the
Lastly, forcing autonomy versus fostering dependence therapist. During this phase, the therapist consultation team
involves acting in ways that inhibit an adolescent’s also continues, addressing the functions of treating the
autonomy (e.g., excessive caretaking, overreliance on therapist and structuring the environment as needed.
parents) versus parents’ severing ties with the adolescent Continuing treatment in a separate, second phase with
such that he or she is prematurely forced to separate and reduced intensity allows for clients to feel an increased
become self-sufficient. Adolescents and families tend to sense of mastery without removing structural resources that
vacillate between these polarities, causing extreme distress. may be helping to maintain progress. Further, increasing
Thus, the central dilemma of treatment is to help adoles- the length of treatment with a graduate group offers ado-
cents and parents move to a balanced position representing lescent clients the opportunity to use the skills that they
synthesis. learned in the first stage of treatment to broaden treatment
123
goals once skills acquisition has occurred. Importantly, this ideation or attempt (Katz et al. 2004) are reviewed. Then,
two-stage approach allows for reallocating staff resources five studies that adapted DBT for other diagnoses associ-
to ensure that therapists are available for more intensive ated with emotion dysregulation are summarized; specifi-
treatment of new clients who are beginning DBT. cally, one study each of youth with ODD (Nelson-Gray
Sixth, the number of skills taught within each module et al. 2006), BD (Goldstein et al. 2007), BED (Safer et al.
was slightly reduced and a fifth adolescent-specific skills 2007), both AN and BN (Salbach-Andrae et al. 2008), and
module was added. Most of the original DBT skills were TTM (Welch and Kim 2012). Lastly, six studies that
maintained because there is no theoretical or empirical investigated DBT for adolescents in diverse settings rather
basis for which skills to include or eliminate. In addition to than with specific psychiatric or behavioral problems are
the four original DBT skills modules (i.e., mindfulness, reviewed; including, correctional facilities (Shelton et al.
interpersonal effectiveness, emotion regulation, distress 2011; Trupin et al. 2002), residential treatment centers
tolerance), a fifth skills module, walking the middle path, (Sunseri 2004; Wasser et al. 2008), long-term inpatient
was developed for adolescents and their families. This units (McDonell et al. 2010), and day treatment programs
module teaches validation of self and others, behavioral (Charlton and Dykstra 2011). See also Groves et al. (2012)
principles (i.e., how to reinforce, extinguish, punish, and for a review of the adolescent DBT outcome literature
shape behavior), and three adolescent–family dialectical through 2008. The review concludes with a discussion of
dilemmas (described above) with the goal of finding the limitations of current research and considerations for future
middle path, or balanced synthesis, in each dilemma. The directions.
dialectical dilemmas are introduced in the multifamily Five open trials of DBT for adolescents with BPD
skills training groups and are targeted in individual and symptoms plus suicide ideation, suicide behavior, and/or
family therapy sessions. NSSI demonstrated positive results (Fleischhaker et al. 2011;
Lastly, group skills handouts were modified to improve James et al. 2008, 2011; Miller et al. 2000; Woodberry and
their appeal and applicability to adolescents. Modifications Popenoe 2008; see Table 1). These studies were conducted
include simplification of terminology, streamlined language, predominantly with females in outpatient or community
simplification of visual layout to decrease visual overstim- clinic settings and most closely followed the DBT for ado-
ulation (via reduced amount of variability in font size, bold lescents manual (including all four modes of standard DBT
print, underlining, and italicizing), and addition of adoles- plus family involvement; Miller et al. 2007b), aside from
cent-geared graphics. Other important modifications when variations in treatment length (ranging from 12 weeks
teaching skills include adapting examples of each skill to to 1 year). Results indicated improvements in suicide idea-
make them more applicable to adolescents and utilizing more tion (Woodberry and Popenoe 2008), suicide behavior
experiential and in vivo, rather than didactic, methods. (Fleischhaker et al. 2011), NSSI (Fleischhaker et al. 2011;
Thus, DBT for adolescents is based on the same theo- James et al. 2008, 2011), thoughts of NSSI (Woodberry and
retical underpinnings and generally follows the same Popenoe 2008), BPD symptoms (Fleischhaker et al. 2011;
framework, including functions of treatment, targets, Miller et al. 2000), depressive symptoms (James et al. 2008,
modes, and strategies, as standard DBT for adults. How- 2011; Woodberry and Popenoe 2008), hopelessness (James
ever, adaptations involving inclusion of family members in et al. 2008, 2011), dissociative symptoms (Woodberry and
skills training, addition of family therapy sessions, devel- Popenoe 2008), anger (Woodberry and Popenoe 2008),
opment of new adolescent–family dialectical dilemmas, overall psychiatric symptoms (Fleischhaker et al. 2011;
reduction of treatment length, addition of an optional Woodberry and Popenoe 2008), general functioning (James
graduate group, implementation of a new skills module, et al. 2008, 2011; Woodberry and Popenoe 2008), and psy-
and modifications to handouts and delivery of content in chosocial adjustment (Fleischhaker et al. 2011). High com-
skills groups make DBT more applicable and appealing to pletion rates were also reported (63–87.5 %), and in one
adolescents and their families. study, adolescents rated all skills moderately to extremely
helpful (Miller et al. 2000). Two studies demonstrated
Empirical Outcomes maintenance of gains over 8-month (James et al. 2008)
and 1-year (Fleischhaker et al. 2011) follow-ups. Interest-
To date, DBT for adolescents has been evaluated in 18 ingly, Woodberry and Popenoe (2008) also found signifi-
studies published in English-language journals. First, six cant posttreatment improvement in parents’ depressive
studies that targeted youth with BPD features plus suicide symptoms.
ideation, suicide behavior, and/or NSSI (Fleischhaker et al. Similarly, two quasi-experimental studies (i.e., lacking
2011; James et al. 2008, 2011; Miller et al. 2000; Rathus random assignment) indicated improvement following
and Miller 2002; Woodberry and Popenoe 2008) and one DBT when compared with TAU (psychodynamic psycho-
study that targeted adolescents hospitalized for suicide therapy) for mostly female adolescents with BPD features
123
plus suicide ideation or recent suicide attempt (Rathus and One case study and one case series of DBT for youth
Miller 2002) and adolescents hospitalized on an inpatient with EDs and one case study of DBT for an adolescent with
unit for suicide ideation or attempt (Katz et al. 2004; see TTM also provide support for DBT with these populations
Table 1). Rathus and Miller (2002) implemented DBT in (see Table 2). DBT for adolescents with EDs incorporated
an outpatient setting and closely followed the Miller et al. adaptations, such as reviewing the DBT model of disor-
(2007b) manual; however, Katz et al. (2004) made adap- dered eating behaviors and their association with dysreg-
tations to frequency of treatment modes to make DBT more ulated emotions, providing nutrition psychoeducation,
applicable on an inpatient unit (also, telephone coaching dispelling myths about food, and addressing negative body
was not used). Rathus and Miller (2002) found adolescents issues. A case study of a 16-year-old female with BED who
who received 12 weeks of DBT demonstrated significantly received 21 weeks of individual therapy (with incorporated
fewer psychiatric hospitalizations (0 versus 13 %) and skills review), 4 family therapy sessions, and telephone
higher treatment completion (62 versus 40 %) compared coaching demonstrated reduced frequency and severity of
with TAU, despite youth in the DBT group having sig- binge episodes posttreatment and at 3-month follow-up
nificantly more psychopathology at baseline (i.e., depres- (Safer et al. 2007). A case series of 25 weeks of DBT for
sive and substance use disorders and BPD). There were no females with AN or BN consisting of weekly individual
significant between-group differences in suicide attempts, therapy and adolescent group skills training (parents
likely due to low occurrence in both groups (7.3 %), attended 8 groups), telephone coaching, and consultation
though only one DBT participant made an attempt during team meetings found high treatment completion and sig-
the study versus seven in TAU. DBT participants also nificant posttreatment improvements in behavioral symp-
demonstrated significant reductions in suicide ideation, toms of eating disorders (i.e., restricting, bingeing,
depression, anxiety, general psychiatric symptoms, global purging) and general psychopathology; AN youth also
severity, and BPD symptoms posttreatment; however, these demonstrated significant improvement in body mass index
were not measured in the TAU group and thus could not be (Salbach-Andrae et al. 2008). A case study of 16 weeks of
compared. Katz et al. (2004) found adolescents who DBT for a 15-year-old female with TTM consisting of
received 2 weeks of DBT demonstrated a significant weekly individual therapy with parent check-ins, psycho-
reduction in the number of incidents on the inpatient unit education about TTM, self-monitoring, chain analyses,
(e.g., violence toward self and others) when compared to habit reversal, stimulus control, relapse prevention, and
TAU at posttreatment. In addition, there was a significant DBT skills (mindfulness, emotion regulation, distress tol-
reduction in total number of incidents on the unit when erance) found improvements in hair pulling, emotion reg-
comparing the 6-month period before and after DBT ulation, anxiety, and depression by posttreatment, with
implementation. Both groups also demonstrated significant slight worsening of hair pulling at follow-up (Welch and
reductions in NSSI, depression, and suicide ideation over Kim 2012).
1-year follow-up. Further lending support to the use of DBT with ado-
Studies of DBT for ODD, BD, EDs, and TTM in out- lescents are six studies that adapted and examined DBT for
patient settings similarly demonstrated promising results; youth in specific settings (i.e., correctional facilities, resi-
however, these adaptations deviated significantly from the dential treatment centers, long-term inpatient units, day
Miller et al. (2007b) manual and lacked control compari- treatment programs) rather than with particular psychiatric
sons (see Table 2). An open trial of 16 weeks of adoles- or behavioral targets, though many of these youth pre-
cent-only group skills training with adaptations to improve sented with numerous and severe psychiatric and behav-
compliance (e.g., pizza, financial incentives) for youth with ioral problems (see Table 3). These studies used open
ODD (mostly males) found significant posttreatment designs, uncontrolled groups, or examination of time
improvements in positive behaviors (i.e., interpersonal periods before and after DBT implementation. DBT
strength), ODD and externalizing behaviors, depressive adaptations also significantly deviated from the DBT for
symptoms, internalizing symptoms, and total problem adolescents manual (Miller et al. 2007b). Two studies in
behaviors (Nelson-Gray et al. 2006). An open trial of correctional facilities implemented adolescent-only group
1 year of DBT for youth (mostly females) with BD con- skills training in either a pre–post design with TAU control
sisting of acute treatment and continuation phase with BD and all females over 10 months (Trupin et al. 2002) or an
adaptations (e.g., psychoeducation about BD) and indi- open design with males over 16 weeks (Shelton et al.
vidual therapy, individual family skills training, and tele- 2011). Results indicated improvements in: behavior prob-
phone coaching demonstrated high completion and lems (e.g., aggression, NSSI, classroom disruption) and
satisfaction and significant improvements in suicide idea- punitive responses (Trupin et al. 2002); and coping,
tion, emotion dysregulation, and depression, and nonsig- aggression, impulsive behaviors, negative affect, and self-
nificant improvement in NSSI (Goldstein et al. 2007). control (Shelton et al. 2011). Two studies in residential
123
treatment facilities implemented either all four modes of adolescents with suicide ideation or attempt. Open trials
treatment over 29 months with females (compared lacked comparison groups; thus, it is possible that
29 months before and after DBT implementation; Sunseri improvements were due to nonspecific therapeutic factors,
2004) or individual therapy plus multifamily group skills uncontrolled medication use, passage of time, or other
training over 17 weeks with mostly males and matched factors unrelated to DBT. Quasi-experimental studies used
standard therapeutic milieu control (STM; Wasser et al. TAU control comparisons (psychodynamic psychotherapy)
2008). Results demonstrated significant reductions in pre- but lacked random assignment. Thus, systematic differ-
mature terminations due to self-harm or psychiatric hos- ences between groups may have existed pretreatment and
pitalization (16.7 versus 0 %), number of days clients spent affected outcome. Indeed, Rathus and Miller (2002) noted
in psychiatric hospitals due to NSSI (71 inpatient days youth who received DBT in their study presented with
from 8 clients versus 42 inpatient days from 6 clients), and significantly greater psychopathology than in the TAU
duration of physical restraints and seclusions (median of group.
20 min versus 11 min) following implementation of DBT Studies of DBT for youth with other psychiatric disor-
(Sunseri 2004); and improvement in general psychiatric ders or in specific settings are promising but also have
symptoms, with DBT having a significantly greater impact limitations. First, trials of DBT for ODD and BD were
on depression and STM having a significantly greater evaluated via open trials, while adaptations of DBT for
impact on psychomotor excitation (Wasser et al. 2008). BED and TTM were evaluated in case studies, and DBT for
McDonell et al. (2010) compared youth receiving DBT AN and BN was evaluated in a case series. Lack of com-
in a long-term inpatient unit to historical controls (who parison conditions in these trials limits the conclusions that
received individual and family therapy as needed) over can be made about the efficacy of DBT for these disorders
1 year with three levels of DBT intensity (i.e., DBT milieu, (i.e., improvements may be due to factors unrelated to
DBT milieu plus group skills training, or DBT milieu plus DBT). Second, six studies that examined implementation
group skills training and individual therapy) and found of DBT for adolescents in specific settings (i.e., correc-
significant improvement in global functioning and signifi- tional facilities, residential treatment centers, long-term
cant reduction in number of medications, and significant inpatient units, day treatment programs) did not specify
reduction in NSSI compared with control. Finally, exami- diagnostic or behavioral inclusion criteria. Though these
nation of 19 months DBT adapted for youth with devel- youth presented with comorbid conditions and significant
opmental and behavioral health needs in a day treatment impairment, this design creates a heterogeneous sample of
program (i.e., individual therapy, group skills training, youth with a range of psychiatric and behavioral problems,
consultation team, telephone coaching, milieu behavior some of which may be more responsive to DBT than
management) found increased DBT skills use, ability to others. Also, although four of these studies utilized com-
identify maladaptive emotions, thoughts, and actions, and parison conditions (i.e., pre–post intervention records with
significant correlation between problem behaviors (e.g., TAU comparison, matched samples across agencies, his-
argued, tried to avoid work, tried to hurt self or others, torical controls, and time periods before and after DBT
attempted suicide), negative thoughts, and negative feel- implementation), groups were uncontrolled and random
ings with month (i.e., as number of months in DBT assignment was not used; thus, systematic group differ-
increased number of problem behaviors, negative thoughts, ences may have affected outcome.
and negative feelings decreased; Charlton and Dykstra Other limitations common to most aforementioned
2011). Collectively, findings from pre–post, uncontrolled, studies of DBT for adolescents included relatively small
and quasi-experimental studies examining DBT for ado- sample sizes consisting mostly of females. Though
lescents with a range of psychiatric disorders and problem McDonell et al. (2010) included 210 youth in their examina-
behaviors in various settings have yielded promising tion of DBT in a long-term inpatient unit (n = 106) versus
results. historical controls (n = 104), among outpatient imple-
mentations of DBT with adolescents, which is the recom-
Limitations mended form of treatment delivery outlined in both adult
(Linehan 1993a, b) and adolescent (Miller et al. 2007b)
Despite advances in research on DBT for adolescents, manuals, sample sizes ranged from 1 to 111 (though of
significant limitations exist. First, although DBT was N = 111, only 29 received DBT and 82 received TAU).
originally adapted for adolescents with BPD features and Some studies went to great lengths to improve compliance
suicide ideation, suicide behavior, and/or NSSI, only five and retention (e.g., financial incentives, meals, outreach
open studies and one quasi-experimental trial have exam- strategies; James et al. 2011; Nelson-Gray et al. 2006;
ined the efficacy of DBT for this population. One quasi- Woodberry and Popenoe 2008), which limits the ecological
experimental study also evaluated DBT for hospitalized validity and generalizability of these findings. Also, most
123
measures assessed symptoms and functioning through dissemination studies are conducted, RCTs are needed to
adolescent self-report. Treatment fidelity was not specifi- determine for which adolescent disorders or problem
cally measured in any study and treatment length ranged behaviors DBT is effective.
from 2 weeks to 29 months, with some adaptations devi- Miller et al. (2007b) provided a theoretically sound and
ating considerably from the format and structure of DBT developmentally appropriate adaptation of DBT for sui-
outlined in manuals (Linehan 1993a, b; Miller et al. cidal adolescents. Future research should aim to evaluate
2007b). In addition, only five studies included follow-up clinical components and outcomes of this adaptation. For
data, and during these periods, treatment was uncontrolled. example, optimal length of treatment should be investi-
Lastly, most trials either did not report medication use, or gated empirically. Current studies rely on adaptations of
this was uncontrolled. As a result of these deviations in DBT with various lengths, ranging from 2 weeks to
terms of treatment format, structure, and content, the dif- 29 months. Though the original manual (Miller et al.
ferent adolescent psychiatric disorders and problem 2007b) called for 16 weeks of outpatient treatment with
behaviors to which DBT was applied, and various study optional continuation, adolescents with different presenting
designs and lengths of follow-up assessments, it is difficult problems or in different settings may benefit from alternate
to synthesize and draw overarching conclusions about the lengths of treatment. In contrast, 16 weeks may indeed be
research on DBT for adolescents. the optimal length of DBT for adolescents. Empirical
evaluation would provide a more definitive answer to this
Future Directions question. In addition, evaluation of the most pertinent and
effective DBT components and skills for adolescents and
Given limitations of current studies examining DBT for their families should be considered. Most of the original
adolescents, additional research is needed. Research on DBT treatment modes and skills were maintained in the
DBT for adolescents is relatively limited (18 studies pub- adolescent DBT manual (Miller et al. 2007b) because there
lished in English-language journals), and to date, there are is no theoretical or empirical basis for which components
no published RCTs. Given that the RCT design is the gold to include or eliminate. However, some adaptations of
standard for determining treatment efficacy (Chambless DBT for adolescents only included some of the treatment
et al. 1996, 1998; Chambless and Hollon 1998), multiple strategies, modes, and skills. Similarly, particular skills
RCTs are needed to evaluate whether DBT can be con- may be more effective than others for adolescents and their
sidered efficacious for adolescents. Currently, RCTs families. Determination of the most pertinent treatment
examining DBT for adolescents are underway, the results components and skills may indicate specific strategies,
of which will direct the future of adolescent DBT research modes, and modules to emphasize, which would be espe-
considerably (Groves et al. 2012). Stringent RCTs cially informative since treatment of adolescents is typi-
employing control comparisons similar to those used in cally much shorter in duration than the original DBT
adult efficacy studies (i.e., starting with WLC or TAU protocol.
comparisons, followed by nonbehavioral active treatment
controls) would provide more definitive evidence for the
efficacy of DBT for adolescents. Such RCTs should also be Conclusion
conducted by diverse research groups, measure and dem-
onstrate adherence to the manual, consider allegiance Given positive outcomes among adults with various psy-
effects, include semistructured assessment of adolescent chiatric and behavioral impairments, DBT has been adap-
psychiatric symptoms, and assess functioning at long-term ted for use with adolescents who present with similar
follow-ups. problems. Current adaptations of DBT target youth with
Because current empirical evidence is strongest for BPD features, suicide ideation and behavior, NSSI, ODD,
adults and adolescents with BPD features plus suicide BD, EDs, and TTM. DBT has also been applied transdi-
ideation, suicide behavior, and/or NSSI, RCTs should first agnostically among youth with varied psychiatric and
target youth with these symptoms and behaviors. If efficacy behavioral problems in correctional facility, residential,
is demonstrated, additional RCTs examining different long-term inpatient, and day treatment settings. Rationale
disorders in adolescents with an underlying emotion reg- for using DBT with these adolescents rests in the common
ulation dysfunction could be initiated. Similarly, studies in underlying dysfunction in emotion regulation across ages,
diverse settings should aim to create more homogenous diagnoses, and problem behaviors. Treatment adaptations
samples of youth with similar presenting problems and and length vary depending on the presenting problem and
defined inclusion/exclusion criteria to test the efficacy of setting. However, most adaptations are modeled after the
DBT for a specific disorder or problem behavior. Also, adolescent DBT manual (Miller et al. 2007b) and involve
before mediator, moderator, dismantling, effectiveness, or inclusion of family members in skills training, addition of
123
family therapy sessions, inclusion of new adolescent– Bedics, J. D., Atkins, D. C., Comtois, K. A., & Linehan, M. M.
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and patient introject during the course of dialectical behavioral
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Although DBT for adolescents has been examined in implementation of dialectical behavior therapy in forensic
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Dialectical Behavior Therapy For Adolescents: Theory, Treatment Adaptations, and Empirical Outcomes

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Clin Child Fam Psychol Rev (2013) 16:59–80

Dialectical Behavior Therapy for Adolescents: Theory, Treatment

Published online: 8 December 2012

Nelson- Pre–post 54 10–15 Oppositional 69 % 16 weeks: weekly Significant posttreatment

Table 3 Studies of dialectical behavior therapy for adolescents in diverse settings

Theory (Linehan 1993a). Given that adolescents can also present

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