Q&A: Pat Harvey and Britt Rathbone, Authors of DBT for At-Risk Adolescents

Editor’s note: The following is a Q&A with Pat Harvey, ACSW, LCSW-C, and Britt H. Rathbone, ACSW, LCSW-C, authors of Dialectical Behavior Therapy for At-Risk Adolescents: A Practitioner’s Guide to Treating Challenging Behavior Problems.

Why are DBT methods so well-suited for teens’ emotions and psychological development?

Young people spend the bulk of their day in an educational setting, where they are taught new information and skills and given homework to consolidate learning, and where the level of challenge is continually and gradually increased. There is ample research in the education world to support this approach. Why not use a similar approach when teaching young people how to manage mood? DBT uniquely provides warmth and validation while continuously pushing for changes in behavior and it provides adolescents with specific skills that they can benefit from immediately. It does all of this in a way that is not stigmatizing, promotes self-acceptance, and utilizes behavioral principles that make sense to therapists, young people, and parents. As many providers state when asked why they choose to provide DBT to adolescents, “It works.”

How does DBT help an at-risk youth learn how to regulate his or her emotions, and how can that manifest in behavior?

Many young people who exhibit at-risk behaviors (self-harm, aggression, disordered eating, substance use, and so on.) report that emotions rule their lives. They feel that their behavior is hijacked by their urges and feelings. Specific techniques are provided in DBT to combat the impulsivity so prevalent in individuals who have trouble with emotionally driven behaviors. Additionally, DBT helps adolescents learn (1) to be aware of their thoughts, feelings, and behaviors and how they influence each other, and (2) to manage these responses effectively using specific skills, while maintaining a steady focus on goals that they identify as meaningful. While it requires learning new skills as well as ongoing practice in using these skills deliberately and effectively, as adolescents begin to integrate the new self-awareness and learning, their behavioral responses become healthier and their commitment to treatment becomes stronger.

What is a “parent coach” and why is this an important therapeutic role?

Parents who live with an at-risk adolescent and face the intensity of their emotions daily often need their own support and a place where they can be validated and accepted. A parent coach is a therapist trained in DBT who works specifically with the parents to provide validation and understanding as well as specific ways that they can use DBT skills (such as validation, behavioral principles, and opposite action) to parent their adolescent more effectively. The parent coach is also able to help the parents manage their own emotions which further contributes to effective parenting. In addition, the parent coach is able to provide guidance about setting limits, having expectations, and being consistent in observing limits. The parent coach thus enables the adolescent’s individual therapist to work on developing a trusting relationship with the adolescent without also having to balance the needs of the parents.

What role does the adolescent’s family or other support system play during treatment? What about after treatment has been completed?

The adolescent’s family and support system are very important in creating an environment that provides validation for the pain and distress the adolescent feels, rather than inadvertently dismissing or trivializing her very real feelings and concerns. This validation, in and of itself, de-escalates intense emotionality and helps the adolescent make healthy changes in her behaviors. In addition the family needs to reinforce healthy behaviors in the adolescent and be less attentive to the unhealthy or dysfunctional behaviors so the adolescent will use the healthier behaviors to get her needs met and to manage her emotions. Parents who may be afraid of the reaction to limits or expectations might inadvertently reinforce unhealthy or disruptive behaviors by giving the adolescent what she wants when she objects or by minimizing reasonable requests. When parents learn to respond not in fear but effectively, with limits and expectations, the adolescent can begin to practice skillful responses to the environment that can then generalize to other situations. A parent coach can help parents manage their own anxieties and fears and respond effectively to the behaviors of their adolescents.

Why is it so important to create a validating environment?

Validation is necessary for change; adolescents will only make changes if they feel they are understood and acknowledged first. Adolescents often become angrier when they feel that they are not understood or that nobody “gets it.” Validation is a way that adolescents come to know that someone in their environment ‘gets it,’ and can acknowledges that they are trying to manage their pain and distress in the best way they know. When an adolescent feels validated, she is more willing and better able to work on changing his behaviors.

How can you help the parent/guardian and adolescent come to consider and respect the other’s perspective?

A DBT assumption, taught to both adolescents and their parents, is that there is no one truth. The theory of dialectics teaches that there are multiple truths and perspectives, and that contradictions are part of life. Given this fact, it is important to search for and accept what is valid to the other person. With this understanding and these guiding principles, DBT helps adolescents and parents understand that there is a “kernel of truth” in what the other is saying, even if they disagree with or don’t like it. DBT helps parents understand their adolescents and adolescents understand the perspective of their parents. Parents and adolescents learn to accept that they may not agree and they can still recognize and acknowledge what may be valid to the other person. This is modeled in sessions by acknowledging what is valid to the adolescent or the parent in the session even when providers do not agree.

How can clinicians conceptualize treatment and set goals?

DBT assumes that all adolescents are wired to approach positive experiences, and avoid aversive ones. DBT providers see all behavior as having a cause and a purpose, and acknowledge that behaviors that are self-destructive and/or dangerous also benefit the adolescent in some way, or they would not engage in them. DBT sees dangerous behaviors as attempts to manage or avoid painful affect, and acknowledges the pain and suffering that underlies these behaviors. Young people are intrigued by the promise of getting their goals met (for example, relief from distress) in ways that do not result in further pain and suffering. We assume that adolescents do not have the skills to manage emotions more effectively (or they would be using them), or they have not learned to generalize learned skills to the environments that are most challenging. Because the skills taught in DBT focus on emotion management, interpersonal effectiveness, distress tolerance, and improving quality of life, the treatment dovetails naturally into goals articulated by adolescents.

How do you address self-harm behaviors?

DBT focuses relentlessly on eliminating self-harming behaviors, and these behaviors are addressed session after session until they no longer occur. DBT providers use specific tools to collaboratively analyze these behaviors and determine what causes them, what reinforces them, and what function they serve. Then DBT provides alternatives, and supports the adolescent in using these alternatives through coaching and other out-of-session support until they are learned and applied effectively. DBT providers assume that adolescents will stop self-harming when they find a more effective way to manage their pain and get their needs met, and then focuses the treatment on doing just that.

For more on the use of DBT with at-risk adolescents, check out Dialectical Behavior Therapy for At-Risk Adolescents: A Practitioner’s Guide to Treating Challenging Behavior Problems.

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