This feature by Lorie Ritschel, PhD is Part 1 of 2 in a series about DBT for adolescents. In this first part, Lorie addresses her experience as a DBT therapist working with adolescents and a couple of notable differences between DBT and DBT-A.
In my role as a trainer and supervisor, I have often encouraged talented DBT therapists who work with adults to consider working with teens. More often than not, that suggestion is met with body language that suggests some level of apprehension, mild distaste, or an outright “not a chance,” often followed by some explanation regarding the absurdity of my suggestion.
Those responses generally fall into one of two general camps: “I’m scared of teenagers” or “I don’t want to work with the parents.” Early in my career, I fell into a third category: “all of the above.”
I am trained as an adult psychologist so didn’t have a ton of courses on adolescents in grad school. I was also nervous about the basics, like how to properly conduct an intake with a minor and how much to involve caregivers in treatment. As a postdoc, though, I thought a lot about how long my adult clients had been suffering (not to mention the fact that the DSM5 states that personality disorders begin to develop in adolescence!) and I frequently had the thought “I wish I could have helped this person when they were younger.”
So, I sought more training in working with adolescents. To be fair, some of them WERE scary, and some of the parents were really tough to work with…and, on the whole, I loved it. I found teenagers to be far more moldable than many of my adult clients – more willing to try new things, to take feedback. I have been asked many times throughout my career whether teenagers can really learn complex skills like radical acceptance or if they can fully participate in a chain analysis. I can tell you now with confidence that the answer is yes. They can do all those things and much, much more. Many of them will truly amaze you with their resilience and willingness, even in very difficult family situations. I must say at least once a day, “I know you didn’t jump into the pool, AND you still have to find a way out.”
While DBT with adolescents has considerable overlap with standard DBT, there are several notable differences.
First, DBT-A includes a fifth module to be addressed in skills training groups called Walking the Middle Path. In this module, we teach teens and caregivers about the basic principles of dialectics and dialectical thinking, including an introduction to common dialectical dilemmas that tend to occur in families with teens (e.g., pathologizing the norm vs. making light of problem behaviors).
In addition, we teach validation (in more detail than when we teach the GIVE skills), and we teach the principles of behaviorism, including using reinforcers and punishers to change behavior in ourselves and others. Though these skills are often taught to our adult clients – including via several of the optional handouts included in the adult skills training manual – there is a differential focus on the Middle Path skills with teens, as they are critically important for achieving change in both the teen and their environment.
Second, DBT-A was designed to systematically include caregivers with the goal of increasing the likelihood of skills usage and reinforcement in the home environment (and an ancillary goal of helping the entire family system). Of course, not all caregivers are willing to be regularly involved in treatment; that is, they may not see themselves as part of either the problem or the solution. Nevertheless, caregivers must typically consent to treatment and are often critically involved in the logistical aspects of treatment (e.g., transportation, payment).
Moreover, caregivers can help reinforce skills use in the home and in the youth’s environment more generally, and they often play a critical role in helping the therapist structure the child’s environment to be as effective as possible. For example, a therapist may determine that their teen client meets criteria for ADHD, or they suspect a learning disability of some sort that may be interfering with school functioning. While the therapist can make recommendations for additional testing, medication consults, or educational supports, it is often the job of the caregivers to ensure that these ancillary supports are put in place.
Read here for part two, in which we will address caregiver therapy interfering behavior.
Lorie Ritschel, PhD is a certified DBT therapist through the DBT-LBC and is an expert trainer of DBT and the DBT Prolonged Exposure protocol. She is a co-founder of the Triangle Area Psychology Clinic (TAP), an outpatient clinic in Durham, NC that specializes in DBT and other empirically supported treatments for adolescents, adults, couples, and families.. Read her full bio here.