DBT for Adolescent Depression: What Parents Need to Know
Navigating adolescent depression with your child can be challenging. Acknowledging their struggles while at the same time encouraging them to work on those struggles takes a skilled hand and a great deal of expertise to navigate effectively. Dialectical Behavior Therapy (DBT) seeks to help teens (and their parents) process important feelings and build actionable blueprints for coping and healing.
This article discusses DBT for adolescent depression, including tips and tricks to use at home, as well as information on different types of DBT programs and actions parents can take to make their child’s DBT treatment more effective.
What Is DBT?
Dialectical Behavior Therapy (DBT) is a skills-based therapy that aims to help residents “build a life worth living.” This means identifying and pursuing the things that are important to their lives. DBT therapists aim to provide patients with the tools to pursue these ends, operating on a few central principles:
- Two opposing things can be true at the same time. DBT takes a good-faith approach to the doctor-patient relationship, believing simultaneously that (1) everyone is doing the best they can and that (2) they can (and should) do better. This core belief creates the “dialectical” aspect of DBT treatment.
- Therapy is a relationship between equals. DBT explicitly challenges the existing power structures of traditional therapy by providing patients with the ability to address problems they have with their therapists directly, as would happen in a normal, everyday relationship. Emphasizing this shift in what is typically a hierarchical relationship allows patients to address issues they may be otherwise reluctant to talk about.
DBT was developed by Dr. Marsha Linehan as a response to Cognitive Behavior Therapy (CBT), which she saw as being insufficient to address chronic mental health conditions like depression, BPD, or bipolar disorder. Infusing aspects learned during her time as a zen student, Linehan developed DBT to address these shortcomings.
DBT has four facets of treatment, including:
|Structured Individual Therapy||Skills Training||In-the-Moment Coaching||Consultation Team|
|A regularly scheduled meeting, typically 1-2 times a week, in which the patient has a 1-on-1 conversation with the therapist about their feelings.||A weekly group meeting focusing on developing essential skills. Family is often brought into these sessions to learn the skills with the patient.||DBT therapy provides 24/7 contact with the therapist to avoid engaging in negative behaviors.||An internal-facing team that “therapizes the therapist,” so to speak, providing them with a clear and removed perspective on the patient’s case.|
Finally, the goal of DBT therapy is to be short-term; while it’s important to acknowledge that some residents may require ongoing therapy, the goal of treatment is to help patients work towards their goals until treatment is no longer necessary and they have the tools to pursue these ends on their own. This time frame varies depending on the patient, but averages for treatment are typically between 3-4 months and a year.
How Effective Is DBT for Adolescent Depression?
Dialectical Behavior Therapy is one of the most researched forms of therapy in the world. Since its development in the 1980s, the effects of DBT have been successfully replicated in over 40 randomized studies around the world. It has been used to treat adolescents with depression, BPD, bipolar disorder, and other behavioral conditions.
When treating adolescents, DBT has been used to treat the following symptoms:
- A depressed mood most of the day or increased irritability
- A loss of interest or pleasure in things
- Significant weight loss/failure to gain weight if they are still growing
- Changes in appetite or sleep schedule
- Lack of energy below the resident’s baseline
- Feelings of worthlessness or excessive guilt
- Diminished ability to think or concentrate
- Recurrent thoughts of death
One of the challenges associated with a depression diagnosis is the close relation that depression has to grief. Often, adolescent patients may experience grief that turns into a depressive episode, which can require further examination on the basis of severity and duration of those feelings.
DBT achieves these results by helping residents develop their four vital skills (emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness), which DBT borrows and modifies from Zen Buddhism. These skills provide patients with the tools they need to go through their lives without being overwhelmed by their depression. We detail each in the sections below.
The Essential DBT Tools
Emotional regulation helps patients encounter harmful emotions without being overwhelmed by them. DBT helps patients decrease the frequency of unwanted emotions as well as the vulnerability and suffering that these emotions cause.
Emotional regulation focuses first and foremost on helping the patient understand their emotions, which they may have trouble with due to several factors:
- Lack of skill
- Social reinforcement
It also provides patients with the terminology to describe those emotions and prompts them to contextualize their feelings according to the facts surrounding them. For example, someone feeling envy might consider the event that led to this feeling, whether or not there is a threat, and whether or not their feeling seems appropriate.
Whereas emotional regulation techniques examine emotions after the fact, distress tolerance focuses on providing adolescents with the practical skills to handle triggering situations in the moment. This helps teens experiencing depressive episodes manage the worst of their depression until they can revisit those unwanted emotions from a more meditative and analytic mindset.
Examples of distress tolerance techniques include deep breathing, splashing cold water on your face, or even intense exercise. Another common technique is using healthy distractions, such as:
- Playing video games
- Going out for food
- Playing an instrument
- Reading or writing
- Spending time with a loved one
These activities keep the adolescent occupied until the initial feeling has passed. It’s important to fit these techniques to the patient – for example, some teens may not appreciate being told to do chores when they are already in distress. In these situations, switch to a different method until you find one that works for that child.
A final note: Once those feelings have passed, it’s critical to revisit those feelings with the adolescent using emotional regulation techniques. Distress tolerance techniques are critical skills to develop, but those feelings must be addressed and analyzed for treatment to be effective.
As the name implies, interpersonal effectiveness techniques focus on developing your child’s ability to navigate social situations without being overwhelmed. These techniques teach adolescents with depression how to build positive relationships, cut off toxic or unhelpful ones, and maintain balance in their relationships.
Interpersonal skills teach teens with depression to think about what they want from a social situation and the obstacles that stand in the way of that goal. Often, these obstacles include things like:
- Their own emotions
- Focusing too heavily on short-term goals (i.e., “I just want to get through this conversation”)
The DEAR MAN Method
A common technique used in DBT for adolescent depression is known as the “DEAR MAN” method, which consists of:
|Describe||Describe the situation. This step is not always necessary, but developing the skills to do so is vital.||“I’m confused. Didn’t you tell me to meet you here at 6pm?”|
|Express||Express yourself. Remember that the person you are talking to may not understand how you feel.||“When you change plans like this without telling me, it makes me feel like an afterthought.”|
|Assert||Communicate what you want (or don’t want) to the other person.||“From this point on, please make sure to let me know if you can’t make it.”|
|Reinforce||Offer a reward (something minor) to the other person for respecting your boundaries.||“I would really appreciate it if you would.”|
|Stay Mindful||Stick to your communicated goal until the other person acknowledges it.||“I’m not asking for much. Just let me know when you need to change plans.”|
|Appear Confident||Avoid stammering, whispering, shouting, or other behaviors that might be construed as uncertain.||Shoulders back, chin up, use a clear, calm voice and maintain eye contact.|
|Negotiate||See if the other person has a reasonable solution to the problem that respects your boundary.||“Maybe you can text me next time this happens.” “Do you have a solution for this?”|
These skills are some of the hardest for teens to develop and often take time to build. Crafting strong interpersonal skills often requires a good deal of meta-analysis of previous conversations and interactions after the fact to identify whether or not these techniques were applied appropriately.
Teens experiencing depression often have the feeling of being trapped in their emotions, which prevents them from experiencing the present. Practicing mindfulness gives them the skills to do just this, helping them develop techniques to live in the moment rather than the past or the future.
Mindfulness techniques typically include some form of grounding, which is the process of focusing on the physical world around you to bring yourself back into the present. One of the most common grounding techniques is known as the “54321” technique, which encourages patients to list:
- 5 things you can see
- 4 things you can hear
- 3 things you can smell
- 2 things you can touch
- 1 thing you can taste
This whole process typically takes about 1-2 minutes and often has the side effect of creating valuable space between the adolescent and the feelings they are experiencing. For example, a teenager experiencing depression using the “54321” technique can ground themselves in the physical moment while at the same time providing physical context for the feeling that they are experiencing, which allows them to utilize distress tolerance tools.
Where Can My Child Receive DBT for Depression?
|Outpatient||Intensive Outpatient (IO)||Partial Hospitalization Programs (PHP)||Residential Treatment Centers (RTC)|
|Outpatient programs are an entry-level therapy regimen consisting of 1-2 sessions per week with a therapist in either individual or group settings, depending on what the patient prefers.||IO programs are usually preferred for patients requiring additional treatment beyond standard outpatient programs. IO programs are typically several weeks of individual and group therapy, ending after a specified time period.||Ideal for patients requiring more treatment than outpatient programs can offer. These programs utilize a combination of individual and group therapy 3-5 times a week for as long as the patient needs.||Typically reserved for patients who have already seen poor results with lower levels of care or who have safety concerns about their health or the welfare of those around them. These centers utilize individual and group therapy 5-6 days a week for as long as the patient needs.|
How to Nurture Your Child’s Strength Through DBT
When thinking about the best way to support an adolescent as they go through DBT, it’s important to foster a supportive environment. This means educating yourself on what kind of depression your child may be experiencing as well as what the DBT process entails. DBT regularly includes family members as a part of the therapeutic process, so your input will be essential for effective treatment.
Beyond these basic steps, however, the most important things you can do are:
- Communicate clearly and openly. Adolescents going through DBT may be experiencing a host of problems (See “How Effective is DBT for Adolescent Depression” for more info) that cause them to misunderstand the world around them. Ensuring you are as straightforward as possible with your child minimizes these experiences.
- Allow your child to set boundaries. DBT relies on a “relationship of equals” to work. As a parent, this can be especially challenging due to the inherent power dynamic of the parent-child relationship; however, it’s critical that your child have the ability to set reasonable goals and to have them respected.
- Encourage self-care. Helping your child identify the things that are important to them allows them to establish what it means to “build a life worth living.” If they enjoy music, for example, encouraging them to play an instrument provides them the arena to make positive choices in the face of negative feelings and thoughts that further their care.
- Be patient and understand. The dialectical aspect of DBT means acknowledging how your child feels, even if you both want it to improve. While DBT is a short-term therapy, it’s important to remember that progress is never linear; patients often experience setbacks in treatment, but it’s important that you see these as challenges for both of you to tackle together rather than them falling short.
- Collaborate with the treatment team. DBT therapists operate with a team of specialists to ensure that patients receive the care they need, and parents are a critical part of that team. As your child begins treatment, provide updates to the rest of the team so that therapists can get a more holistic sense of what the patient is going through to maximize the effect of treatment.
Applying these principles to your child’s daily life not only provides them with the necessary infrastructure to improve, it reminds them that you are on their team, just like the therapists are. This sense of community is essential to healing.
The Gold-Standard Treatment for Adolescent Depression
Understanding how to use DBT for adolescent depression can be a difficult process. Here are the central takeaways:
- DBT is a skill-based therapy designed to help patients “build a life worth living.”
- DBT was designed for patients with chronic behavioral problems like depression, BPD, and bipolar disorder.
- DBT helps patients develop four vital skills: emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness.
- There are a few options for DBT for adolescent depression: Outpatient, Intensive Outpatient, Partial Hospitalization Programs, and Residential Treatment Centers.
- Parents seeking to help their child through this process should be prepared to communicate clearly and openly, allow their child to set boundaries, encourage self-care, be patient and understanding, and collaborate with the treatment team.
At Compass Behavioral Health, we treat depressed and anxious children and young adults with gold-standard, evidence-based treatments that create mastery, a sense of belonging, and a purposeful life. Our residential program is overseen by clinicians certified by the DBT-Linehan Board of Certification®, meaning only the most experienced therapists and medical staff will provide your child with individualized treatment at our employee-owned facility. We also teach valuable Dialectical Behavior Therapy (DBT) skills for parents to use at home to help their children understand and respond to their emotions.
Schedule your free consultation today to learn more about DBT for adolescent depression.
Dr. Nicole Motakef, D.O.
Medical Director of the Compass Residential Treatment Program
Dr Nicole is board certified in general psychiatry as well as child and adolescent psychiatry by the American Board of Psychiatry and Neurology. In addition, she has completed fellowships in integrative and nutritional psychiatry by the Integrativec Psychiatry Institute as well as a course in development and psychoanalysis for children and adolescents at the Newport Psychoanalytic Institute .
Dr. Nicole’s integrative approach to healing combines medical practices with holistic philosophies, such as nutritional psychiatry, which utilizes food as a source of mood stabilization, improved focus, and enhanced well-being.
This is a passion project for all of us here at Compass, and the knowledge contained above comes from 25 years of referring our outpatient teens to residential care all over the country.
For more information regarding how to choose a residential treatment center for teens, or to inquire about the residential program at Compass, please contact us today for a free consultation.