Although experts have suggested that BPD can be meaningfully diagnosed in adolescents, historically, personality disorders were not diagnosed in persons younger than 18. Thus, DBT for adolescents (DBT-A) was targeted specifically at suicidality, as opposed to BPD. However, in defining their criteria for admittance, specific DBT-A programs may seek to identify adolescents with multiple problem behaviors (mood symptoms, self-harm, substance abuse, eating disorder, risky sexual behavior, high-risk activities, and problem behaviors such as stealing and lying) of which suicidality or parasuicidal and self-injurious behavior are prominent. Some programs require the adolescent to meet at least 3 or 4 of the BPD criteria for inclusion.22
The DBT model is predominantly a behavioral one; however, this underlying theoretical approach is melded with Zen mindfulness principles to create a dialectic that simultaneously emphasizes acceptance of the patient in his current state and a willingness to continually work to change and improve. The treatment approach targets 5 functions: enhancing patient capabilities, increasing motivation, structuring the environment to increase the likelihood of success, promoting generalization from therapy to the natural environment, and enhancing therapists’ capabilities and motivation to treat patients effectively (Table 3).
These functions are addressed through 4 modes of treatment: multifamily group skills training, individual psychotherapy, coaching calls, and a consultation team for the therapist. The approach is a “life enhancement” as opposed to suicide prevention program. Thus, if an adolescent can be helped to envision and work toward an obtainable, truly exciting life, then suicide no longer becomes a logical “solution” to the adolescent’s problems. The adolescent’s presenting problems (target behaviors) are behaviorally defined and logically identified as barriers to his self-defined “life worth living.”
Skills training is founded on evidence that patients who present with chronic suicidality lack certain coping skills for soothing and regulating themselves during times of high stress and emotion. The skills taught encompass 5 areas, 4 original to DBT and the fifth added for the adolescent adaptation: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and walking the middle path (adolescent-specific).20,22
Although the structure of skills training is specific, individual DBT sessions are principle- rather than protocol-driven—the clinician is given a toolbox of techniques and a road map based on DBT principles and the patient’s treatment goals and target behaviors. This allows treatment to stay cohesive in the face of a patient population that typically is under a great deal of stress and distress, with multiple problems otherwise resulting in the challenge to treatment of an ever-moving target with “crises du jour” threatening to derail treatment gains. By keeping a principle-driven approach, the therapist and adolescent are able to incorporate the important events of the week into overarching treatment goals without losing momentum or focus.
Goals in DBT follow a hierarchy, with life-interfering behaviors taking precedent, followed by behaviors that interfere with or threaten treatment, quality-of-life–interfering behaviors, and finally skills enhancement. A full description of DBT techniques is beyond the scope of this article, but additional information can be found in primary texts and summary articles.20,22-24