Research On Dialectical Behavior Therapy

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

� Springer Science+Business Media New York 2012

Abstract Dialectical behavior therapy (DBT) was originally

developed for chronically suicidal adults with borderline

personality disorder (BPD) and emotion dysregulation.

Randomized controlled trials (RCTs) indicate DBT is

associated with improvements in problem behaviors,

including suicide ideation and behavior, non-suicidal self-

injury (NSSI), attrition, and hospitalization. Positive out-

comes with adults have prompted researchers to adapt DBT

for adolescents. Given this interest in DBT for adolescents,

it is important to review the theoretical rationale and the

evidence base for this treatment and its adaptations. A solid

theoretical foundation allows for adequate evaluation of

content, structural, and developmental adaptations and

provides a framework for understanding which symptoms

or behaviors are expected to improve with treatment and

why. We first summarize the adult DBT literature,

including theory, treatment structure and content, and

outcome research. Then, we review theoretical underpin-

nings, adaptations, and outcomes of DBT for adolescents.

DBT has been adapted for adolescents with various psy-

chiatric disorders (i.e., BPD, mood disorders, externalizing

disorders, eating disorders, trichotillomania) and problem

behaviors (i.e., suicide ideation and behavior, NSSI) across

several settings (i.e., outpatient, day program, inpatient,

residential, correctional facility). The rationale for using

DBT with these adolescents rests in the common under-

lying dysfunction in emotion regulation among the

aforementioned disorders and problem behaviors. Thus, the

theoretical underpinnings of DBT suggest that this treat-

ment is likely to be beneficial for adolescents with a broad

array of emotion regulation difficulties, particularly und-

erregulation of emotion resulting in behavioral excess.

Results from open and quasi-experimental adolescent

studies are promising; however, RCTs are sorely needed.

Keywords Dialectical behavior therapy � Adolescents � Emotion dysregulation � Treatment adaptation

Introduction

Dialectical behavior therapy (DBT) is a cognitive behav-

ioral treatment originally developed by Linehan (1993a, b)

for the treatment of chronically suicidal individuals, often

with borderline personality disorder (BPD). Positive results

from randomized controlled trials (RCTs) with adults have

prompted researchers to adapt DBT for adolescents who

exhibit similar behavioral and emotional dysregulation.

Given this interest in DBT for adolescents, it is important

to review the theoretical rationale and the evidence base for

this treatment and its adaptations. A solid theoretical

foundation allows for adequate evaluation of content,

structural, and developmental adaptations and provides a

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,

treatment structure and content, and outcome research.

Then, we review theoretical underpinnings, adaptations,

and empirical outcomes of DBT for adolescents. Regarding

the outcome literature of DBT for adolescents, studies of

youth with BPD features, suicide ideation, suicide behav-

ior, and/or non-suicidal self-injury (NSSI) are reviewed in

H. A. MacPherson (&) � M. A. Fristad Department of Psychiatry, The Ohio State University, 1670

Upham Drive, Suite 460, Columbus, OH 43210-1250, USA

e-mail: [email protected]

H. A. MacPherson � J. S. Cheavens � M. A. Fristad Department of Psychology, The Ohio State University,

1835 Neil Avenue, Columbus, OH 43210-1250, USA

123

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

DOI 10.1007/s10567-012-0126-7

Table 1; studies of youth with oppositional defiant disorder

(ODD), bipolar disorder (BD), binge eating disorder

(BED), anorexia nervosa (AN), bulimia nervosa (BN), and

trichotillomania (TTM) are reviewed in Table 2; and

studies that investigated DBT for adolescents in diverse

settings (i.e., correctional facilities, residential treatment

centers, long-term inpatient units, day treatment programs)

are reviewed in Table 3. We conclude with a discussion of

limitations in the adolescent DBT literature and also offer

considerations for future research. Review of research

efforts suggests DBT may be beneficial for adolescents

with a broad array of emotion regulation difficulties, par-

ticularly underregulation of emotion resulting in behavioral

excess. However, RCTs are needed to provide more

definitive evidence for the efficacy of DBT for adolescents.

Dialectical Behavior Therapy for Adults

DBT incorporates aspects of behavioral science, dialectical

philosophy, and Zen practice. Through a balance of change

and acceptance techniques within in a dialectical frame-

work, DBT aims to extinguish maladaptive behaviors and

shape and reinforce adaptive behaviors within a validating

environment, with the goal of helping clients build a life

worth living. The following overview first discusses dia-

lectical and biosocial theoretical underpinnings of DBT

and treatment components, modes, and strategies, as

delineated in the individual therapy and skills training

manuals by Linehan (1993a, b). This section concludes

with a summary of the adult DBT outcome literature.

Theory

Both dialectical philosophy and the biosocial theory underlie

the DBT framework. Dialectical philosophy posits a

worldview emphasizing wholeness, interrelatedness, and

process. It also suggests that there is no absolute truth and

instead emphasizes the existence of opposing forces simul-

taneously (i.e., thesis and antithesis). Dialectical change or

progress comes from the resolution of opposing forces,

through the recognition of the truth or validity in each pole,

into a synthesis. Regarding therapeutic dialog and relation-

ship, dialectics refer to change by persuasion, making use of

oppositions inherent in the therapeutic relationship, and

continually questioning what is being left out of under-

standing, to reduce polarized thoughts and behaviors. In

DBT, dialectics inform a worldview and communication

strategies used to elicit change (e.g., by the therapist high-

lighting opposing viewpoints and simultaneously looking for

truth in each perspective). DBT assumes opposing views can

exist within a person at the same time (e.g., desire to live and

desire to die), which can result in conflict; however,

highlighting and accepting this tension can help both thera-

pist and client move past a treatment standstill and foster

change (Rizvi et al. 2012). The central dialectic in DBT is the

intrinsic tension between acceptance and change (Linehan

1997). For a review of dialectics in DBT, see Fruzzetti and

Fruzzetti (2008).

DBT is a theoretically derived treatment in which skills

and therapeutic techniques were developed to target spe-

cific deficits outlined in Linehan’s (1993a) biosocial theory

of BPD. The biosocial theory suggests that BPD is pri-

marily a dysfunction of emotion regulation (Linehan

1993a), or the ability to monitor, evaluate, and modulate

one’s affective state (i.e., when and what emotions occur,

and how one experiences and expresses those emotions) in

order to accomplish one’s goals (Gross 1998; Thompson

1994). Specifically, the biosocial theory posits that

the emotional, behavioral, interpersonal, cognitive, and

selfdysregulation of individuals with BPD are developed

and maintained through transaction between a biological

tendency toward emotion dysregulation and an invalidating

environment. An early biological vulnerability, expressed

in childhood as impulsivity, has also been identified as a

precursor to the development of BPD (Crowell et al. 2009).

Emotion dysregulation stems in part from emotional vul-

nerability, resulting in frequent and intense emotional

experiences, combined with an inability to adequately

regulate emotions. Characteristics of emotional vulnera-

bility include high sensitivity to emotional stimuli, emo-

tional intensity, and slow return to emotional baseline.

An invalidating environment negates, punishes, and/or

responds erratically and inappropriately to private experi-

ences, punishes emotional displays and intermittently

reinforces emotional escalation, and oversimplifies the ease

of problem solving. Invalidation has also been associated

with increased levels of negative affect and physiological

arousal (Shenk and Fruzzetti 2011). As a result, emotion-

ally vulnerable individuals who experience invalidating

environments have never learned how to label and regulate

emotions, how to tolerate distress, or when to trust their

emotional responses. They tend to invalidate their emo-

tional experiences, look to others for accurate reflections of

reality, and oversimplify the ease of problem solving. From

a biosocial perspective, BPD behaviors resulting from the

transaction between emotional vulnerability and an inval-

idating environment function to regulate emotions or are

consequences of failed emotion regulation. Recent empir-

ical research supports the central role of emotion dysreg-

ulation not only in BPD (Chapman et al. 2008; Glenn and

Klonsky 2009; Gratz et al. 2006; Hughes et al. 2012;

Putnam and Silk 2005; Reeves et al. 2010; Selby and Joiner

2009) but also across broad areas of psychopathology

(Aldao et al. 2010; Kring and Sloan 2010; Nolen-Hoek-

sema 2012).

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

123

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 Range

Inclusion Criteria % Completed DBT Format Outcomes

Miller et al.

(2000)

Pre–post

Outpatient

33

85 % F of 27

youth with

complete

data

14–19 Self-injury in past

16 weeks or

current suicide

ideation; 3 BPD

symptoms

N/A (only

examined

treatment

completers)

12 weeks: weekly

individual therapy and

multifamily skills group,

telephone coaching,

consultation team

Significant posttreatment

improvement in BPD

symptoms; all skills rated

moderately to extremely

helpful; distress tolerance

(self-soothe) and

mindfulness skills (do

what works, stay focused)

rated most helpful

Woodberry

and

Popenoe

(2008)

Pre–post

Community

clinic

46

89 % F

13–18 History of suicide

attempts, self-

injury, and/or

unstable affect

or relationships

in past

3–6 months

63 % 15 weeks: weekly

individual therapy and

multifamily skills group,

telephone coaching,

consultation team

Significant posttreatment

improvements in

depression (d = 0.76 to 0.84), anger (d = 0.94), dissociation (d = 0.69), overall psychiatric

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.

(2008)

Pre–post with

follow-up

Community

clinic

16

100 % F

15–18 History of

[6 months of severe and

persistent

deliberate self-

harm (all

had C 5 BPD

symptoms)

87.5 % 1 year (2 6-month blocks):

weekly individual

therapy and adolescent

skills group, telephone

coaching

Significant posttreatment

improvements in

depression, hopelessness,

NSSI, general

functioning; gains

maintained at 8-month

follow-up

James et al.

(2011)

Pre–post

Community

clinic

25

88 % F

13–17 History of

[6 months of severe and

persistent

deliberate self-

harm (all

had C 5 BPD

symptoms)

72 % 1 year (2 6-month blocks):

weekly individual

therapy and adolescent

skills group, telephone

coaching, consultation

team, outreach strategies

(e.g., meals,

transportation, caregiver

consultation)

Significant posttreatment

improvements in

depression, hopelessness,

NSSI, general

functioning; findings

maintained with intent-to-

treat analyses

Fleischhaker

et al.

(2011)

Pre–post with

follow-up

Outpatient

12

100 % F

13–19 NSSI or suicide

behavior in past

16 weeks; BPD

diagnosis or C3

BPD symptoms

75 % 16–24 weeks: weekly

individual therapy and

multifamily skills group,

telephone coaching,

consultation team

Significant improvements at

1-year follow-up in

suicide behavior (8 youth

attempted pretreatment;

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)

Clin Child Fam Psychol Rev (2013) 16:59–80 61

123

Using dialectical philosophy and biosocial theory,

Linehan (1993a) described common dialectical dilemmas

of individuals with BPD, characterized as six classes of

behaviors that represent the extremes of three continua. At

one end of each continuum is a class of behaviors

hypothesized to be biologically driven, and at the other end

is a class of behaviors thought to be socially determined

and maintained. The first dialectical dilemma, emotional

vulnerability versus self-invalidation, is a tendency to

vacillate between intense, uncontrollable emotional suf-

fering and dismissal, judgment, and invalidation of suf-

fering. Active passivity versus apparent competence, the

second dialectical dilemma, involves passivity in solving

one’s problems while actively engaging others to solve

problems, coupled with the tendency of others to overes-

timate the capabilities of the individual with BPD. Lastly,

unrelenting crises versus inhibited grieving is a tendency to

experience life as a series of extreme problems contrasted

with an inability to experience emotions associated with

trauma or loss. Individuals with BPD are likely to vacillate

between these polarities, causing distress (Linehan and

Schmidt 1995). In line with dialectical philosophy, the

overarching target of treatment is to help patients find the

truth in each end of the dialectic and create a synthesis that

reduces the distress associated with extreme vacillation.

Treatment Functions, Modes, and Strategies

Dialectical philosophy and biosocial theory inform DBT

functions, structure, and strategies. DBT has five functions:

enhancing behavioral capabilities; improving motivation;

assuring generalization of gains to the natural environment;

structuring the environment so it reinforces functional

rather than dysfunctional behaviors; and enhancing

Table 1 continued

Authors Design/Setting N, % Female Age M or Range

Inclusion Criteria % Completed DBT Format Outcomes

Rathus and

Miller

(2002)

Quasi-

experimental

Outpatient

DBT = 29

TAU = 82

93 % F in

DBT

73 % F in

TAU

DBT = 16.1

TAU = 15.0

Suicide attempt

in last

16 weeks or

current suicide

ideation; BPD

diagnosis

or C 3 BPD

symptoms

DBT = 62 %

TAU = 40 %

12 weeks:

DBT = weekly individual

therapy and multifamily

skills group, telephone

coaching, consultation

team

TAU = weekly individual

psychodynamic

psychotherapy and

family therapy

Posttreatment, DBT

adolescents demonstrated

significantly fewer

psychiatric

hospitalizations (0 %

versus 13 %) and higher

treatment completion

compared with TAU; 1

suicide attempt in DBT

versus 7 in TAU; DBT

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.

(2004)

Quasi-

experimental

with follow-

up

Inpatient

DBT = 32

TAU = 30

84 % F in

total

sample

14–17 Recent suicide

attempt or

suicide

ideation;

agreement to

stay in hospital

for the duration

of treatment

N/A

(treatment

completion

required)

2 weeks:

DBT = 4 individual

therapy sessions, 10

adolescent skills group

sessions, consultation

team, DBT milieu

TAU = C1 per week

individual and daily

group psychodynamic

psychotherapy, case

management,

psychodynamic milieu

Posttreatment, DBT

adolescents demonstrated

significant reduction in

number of violent

incidents on unit

compared with TAU;

significant reduction in

total number of violent

incidents on unit

comparing 6-months

before and after DBT;

both groups demonstrated

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

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

123

therapist capabilities and motivation. These functions are

apparent over the course of four stages of treatment, each

with a hierarchy of treatment targets, and four modes of

therapy. In the pretreatment stage, the therapist orients the

individual to treatment and obtains commitment to the

therapist–client relationship and to work on goals. In stage

one, the therapist helps the client attain basic capabilities

(i.e., adding to the skill repertoire) by reducing life-

threatening behaviors (e.g., suicide behavior, self-injury),

therapy-interfering behaviors (e.g., noncompliance, nonat-

tendance), and quality-of-life-interfering behaviors (e.g.,

homelessness, psychiatric disorders), and by increasing

Table 2 Studies of dialectical behavior therapy for adolescents with oppositional defiant disorder, bipolar disorder, eating disorders, and trichotillomania

Authors Design/

Setting

N, % Female Age or

Range

Inclusion Criteria %

Completed

DBT Format Outcomes

Nelson-

Gray

et al.

(2006)

Pre–post

Outpatient

54

15 % F of

32 youth

who

completed

treatment

10–15 Oppositional

defiant disorder

diagnosis

69 %

(5 youth

repeated)

16 weeks: weekly

adolescent skills group

with adaptations to

improve attendance and

homework completion

(e.g., pizza, financial

incentives)

Significant posttreatment

improvements in

positive behaviors (i.e.,

interpersonal strength),

oppositional defiant

disorder and

externalizing behaviors,

depressive symptoms,

internalizing symptoms,

total problem behaviors

Goldstein

et al.

(2007)

Pre–post

Specialty

outpatient

clinic

10

80 % F

14–18 Bipolar I, II, or

NOS diagnosis

with acute

manic, mixed, or

depressive

episode in last

3 months

90 % 1 year: 24 weekly then 12

monthly sessions

alternating individual

therapy with individual

family skills training,

telephone coaching, BD

adaptations (e.g., BD

psychoeducation)

High satisfaction and

significant posttreatment

improvements in suicide

ideation (d = 0.9 and 1.2), emotion

dysregulation (d = 0.3), depression (d = 0.7); nonsignificant

improvement in NSSI

(d = 0.8)

Safer

et al.

(2007)

Case study

with

follow-up

Specialty

outpatient

clinic

1 F 16 Binge eating

disorder

diagnosis

100 % 21 weeks: weekly

individual therapy with

skills, diary card, chain

analyses review, 4 family

sessions, telephone

coaching, ED adaptations

(e.g., DBT model of EDs)

Reduced frequency and

severity of binge

episodes posttreatment

and at 3-month follow-

up

Salbach-

Andrae

et al.

(2008)

Case series

Outpatient

AN = 6

BN = 6

100 % F

12–18 Anorexia nervosa

or bulimia

nervosa

diagnosis

92 % 25 weeks: weekly

individual therapy and

adolescent skills group (8

multifamily groups),

telephone coaching,

consultation team, ED

adaptations (e.g., review

nutrition, body image)

Significant posttreatment

improvements in

restricting (d = 1.2), bingeing (d = 1.9), purging (d = 1.7), general psychopathology

(d = 0.43 to 1.10); AN adolescents

demonstrated significant

improvement in body

mass index (d = -2.6)

Welch

and Kim

(2012)

Case study

with

follow-up

Outpatient

1 F 16 Trichotillomania

diagnosis

100 % 16 weeks: weekly

individual therapy with

skills and chain analyses

review, parent check-in

meetings, TTM

adaptations (e.g., TTM

psychoeducation, habit

reversal, stimulus control)

Improvements in hair

pulling, emotion

regulation, anxiety,

depression

posttreatment; slight

worsening of hair pulling

from posttreatment to

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

Clin Child Fam Psychol Rev (2013) 16:59–80 63

123

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

Authors Design/

Setting

N, % Female Age M or

Range

Inclusion Criteria % Completed DBT Format Outcomes

Trupin

et al.

(2002)

Pre–post

with

control

group

Juvenile

detention

facility

DBT = 45

TAU = 45

100 % F

Mental health

unit = 14.8

General

population

unit = 15.5

TAU = 15.2

Incarcerated

females on

mental health

unit (DBT

n = 22) or

general

population unit

(DBT n = 23;

TAU n = 45)

N/A 10 months:

DBT ? TAU = 1–2

times/week adolescent

skills group

TAU = educational,

recreational,

vocational programs,

group meetings,

behavior modification

Mental health unit

adolescents showed

significant reduction in

behavior problems

(aggression, NSSI,

classroom disruption);

staff on mental health

unit (who received

more DBT training; 80

versus 16 h) showed

significant reduction in

punitive responses

compared to year prior;

no behavior or staff

changes on other units

Shelton

et al.

(2011)

Pre–post

secondary

analyses

Correctional

facility

38

0 % F

16–19 Incarcerated

males with

impulsive

behavior

problems

68 % 16 weeks: weekly

adolescent skills group

Significant posttreatment

improvements in

coping, aggression

impulsive behaviors;

nonsignificant

improvements in

negative affect, self-

control

Sunseri

(2004)

Pre–post

compared

29 months

before and

after DBT

Residential

treatment

facility

68 (n = 42

before DBT;

n = 26 after

DBT)

100 % F

12–18 Resident at

treatment

facility;

commitment to

DBT

N/A 29 months: weekly

individual therapy,

twice weekly

adolescent skills

group, telephone

coaching, consultation

team

After DBT

implementation,

significant reductions

in premature

terminations due to

self-harm or

psychiatric

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

et al.

(2008)

Pre–post

with

control

group

(matched)

Residential

treatment

facility

DBT = 12

STM = 12

25 % F

DBT = 14.7

STM = 14.6

Resident at

treatment

facility

N/A (selected youth

who already

completed DBT)

17 weeks:

DBT = weekly

individual therapy and

multifamily skills

group

STM = family, group,

individual, behavioral,

medication treatment

General psychiatric

symptoms improved

posttreatment for both

groups; DBT

adolescents had

significantly greater

reduction in

depression; STM

adolescents had

significantly greater

reduction in

psychomotor

excitation

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

123

behavioral skills. In stage two, the therapist helps the client

replace quiet desperation with normative emotional expe-

riencing by decreasing posttraumatic stress. In stage three,

the therapist helps the client achieve ordinary happiness

and unhappiness and resolve problems in living by

increasing respect for self and achieving individual goals.

Finally, in stage four, the therapist helps the client resolve a

sense of incompleteness and attain the capacity for freedom

and sustained contentment. Most of the empirical research

on DBT has focused on stage one targets; however, flexi-

bility offered by the DBT stages allows for the application

of DBT to individuals with varying degrees of dysfunction

(Lynch et al. 2007b).

Aforementioned functions and stages of treatment are

accomplished via four modes of therapy: weekly individual

therapy; weekly group skills training; as-needed telephone

coaching; and weekly therapist consultation team meetings

(Robins and Rosenthal 2011). The individual therapist is

responsible for addressing motivational problems, treat-

ment planning, working on progress toward goals, and

assessing and problem-solving crises and skill deficits.

Other modes of treatment revolve around the individual

therapy (Linehan 1993a). Individual therapy is organized

around and sequentially targets the aforementioned hier-

archy of behaviors occurring either in session or reported

on the client’s weekly diary card, a monitoring tool on

which clients record daily ratings of emotions, problem

behaviors, and skills use (Rizvi et al. 2012). For example, a

therapist treating a client in stage one would first address

suicide or self-injurious behavior, followed by any forms of

Table 3 continued

Authors Design/

Setting

N, % Female Age M or

Range

Inclusion Criteria % Completed DBT Format Outcomes

McDonell

et al.

(2010)

Pre–post

with

historical

control

group

Long-term

inpatient

unit

DBT = 106

(from 2000 to

2005)

Control = 104

(from 1995 to

1999)

58 % F

12–17 Admitted to

inpatient unit

N/A 1 year: 3 DBT intensity

levels (unknown

frequency) = DBT

milieu (chain analyses,

behavior interventions,

individual skills); DBT

milieu ? adolescent

skills group; DBT

milieu ? adolescent

skills group ?

individual therapy; all

with consultation team

Control = individual

and family therapy as

needed

DBT adolescents

demonstrated

significant

improvement in global

functioning and

significant reduction in

number of

medications; compared

with control, DBT

adolescents

demonstrated

significant reduction in

NSSI

Charlton

and

Dykstra

(2011)

Pre–post

Day

treatment

program

19 Unknown Enrolled in day

treatment

program for

developmental

and behavioral

health needs

52 % moved to less

restrictive setting;

16 % remained in

day program; 19 %

moved to more

restrictive setting;

16 % lost to

follow-up

19 months: weekly

individual therapy,

twice weekly

multifamily skills

group (when family

available), telephone

coaching, consultation

team, adaptations for

intellectual disabilities

(e.g., concrete and

simplified language

and handouts)

Adolescents

demonstrated

increased DBT skills

use, ability to identify

maladaptive emotions,

thoughts, actions;

significant correlation

between problem

behaviors (e.g., argued,

tried to avoid work,

tried to hurt self or

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

Clin Child Fam Psychol Rev (2013) 16:59–80 65

123

noncompliance or behaviors interfering with treatment,

followed by Axis I disorders or other life problems, and

finally followed by skill building. Strategies for addressing

problem behaviors are described below.

Clients also participate in weekly group skills training.

Groups are conducted with a primary and coleader and range

from 2 to 2.5 h, with the first half devoted to homework

review and the second half spent teaching new skills (i.e.,

mindfulness, distress tolerance, emotion regulation, inter-

personal effectiveness). Mindfulness involves finding the

synthesis between extremes by orienting to the truth in each

position. These skills also include focusing attention by

observing, describing, and participating in the present

moment without trying to change one’s present experience

and while assuming a nonjudgmental stance, focusing

awareness on one thing at a time, and developing effective-

ness (i.e., doing what is needed to achieve one’s goals).

Mindfulness skills are central to DBT and thus are woven

throughout the other skills modules. Distress tolerance tea-

ches impulse control, distracting, and self-soothing strate-

gies for tolerating aversive contexts, surviving crises, and

radically accepting situations that cannot be changed without

resorting to dysfunctional behavior. Emotion regulation

teaches methods for identifying and describing emotions,

determining whether an emotion is justified by current cir-

cumstances, modulating emotions via acting opposite to the

emotion or problem solving, reducing vulnerability to

unwanted negative emotions, and increasing experience of

positive emotions. Finally, interpersonal effectiveness tea-

ches assertiveness skills aimed to help clients achieve their

objectives in interpersonal interactions while also main-

taining positive relationships and their self-respect. These

skills are taught over 6 months and then repeated. Following

the treatment hierarchy, group skills training targets: ther-

apy-destroying behaviors; skills acquisition, strengthening,

and generalization; and therapy-interfering behaviors.

Clients are encouraged to use as-needed telephone

coaching calls if they are experiencing suicide or self-

injurious urges, if they need help utilizing a skill or do not

know what skill to use, or if there is a rupture in the

therapeutic relationship. These calls are typically of short

duration (5–15 min) and consist of the therapist quickly

assessing the client’s problem and helping to identify the

most effective skill to use in the current situation. How-

ever, clients are prohibited from calling the therapist within

24 h of suicide or self-injurious behaviors in order to avoid

inadvertent reinforcement via therapist attention and

because the client has already used a strategy to relieve

distress (albeit maladaptive) instead of seeking assistance

from the therapist in identifying an adaptive skill. Clients

may call during this 24-h period to receive coaching for

medical attention and/or if the client is having urges to self-

harm again.

Lastly, weekly therapist consultation team meetings

(1–2 h) hold therapists within the therapeutic frame, bal-

ance therapists’ interactions with clients, address problems

that arise in treatment, increase adherence to DBT princi-

ples, and increase therapists’ motivation and capabilities in

delivering DBT. During consultation team, mindfulness is

first practiced and then an agenda is set according to the

aforementioned target hierarchy and therapists’ needs (i.e.,

help with individual clients or support when feeling burned

out). Together, these treatment modalities (i.e., individual

therapy, group skills training, telephone coaching, consul-

tation team meetings) aim to reduce clients’ dysfunctional

behaviors in the presence of dysregulated emotion.

Finally, specific treatment strategies are used within the

four modes of treatment to achieve the functions and tar-

gets outlined in DBT (Robins and Rosenthal 2011). Dia-

lectical strategies foster change by highlighting opposing

viewpoints and simultaneously looking for truth in each

perspective. A dialectical therapeutic relationship is con-

stantly balancing acceptance and change, flexibility and

stability, nurturing and challenging, and a focus on capa-

bilities and deficits, with the goal of achieving syntheses.

Dialectical strategies also target behavioral extremes and

rigidity and highlight contradictions in the client’s thoughts

or behavior by offering alternative viewpoints, encouraging

synthesis between opposing perspectives, and promoting

dialectical thinking and acting. Validation strategies

involve the therapist’s acceptance of the client and serve to

communicate to the client that his or her responses make

sense within the current context or are what would be

expected of almost anyone in a given situation (Linehan

1997). Stylistic strategies refer to style and form of thera-

pist interaction and include both reciprocal (e.g., responsive,

genuine) and irreverent (e.g., matter-of-fact, unexpected)

communication. Together, dialectical and stylistic strategies

produce the movement, speed, and flow characteristic of

therapist–client interactions in DBT.

Problem-solving strategies are the primary change

strategies in DBT and involve first understanding and

labeling a selected problem behavior (e.g., suicide behav-

iors, self-injury) via a behavioral chain analysis that iden-

tifies vulnerabilities, events, thoughts, feelings, sensations,

and behaviors that led up to the problem behavior, as well

as consequences of the behavior. Subsequently, a solution

analysis is conducted to identify points of intervention that

would disrupt the chain of events and prevent the problem

behavior from recurring, with emphasis on rehearsal and

troubleshooting. DBT has four sets of change procedures:

skills training, contingency management, exposure strate-

gies, and cognitive modification. Skills training teaches the

client new skills. Contingency management provides a

consequence that influences the probability of a client’s

behavior occurring again. Exposure provides non-

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

123

reinforced exposure to cues associated previously, but not

currently, with a threat. Cognitive modification changes the

client’s dysfunctional assumptions or beliefs. Finally, when

problems in the client’s environment interfere with func-

tioning or progress, the therapist employs case manage-

ment strategies by either consulting with the client on how

to interact effectively with the environment or intervening

directly when the environmental contingencies are very

powerful. Collectively, these treatment functions, modes,

and strategies aim to reduce problematic behaviors asso-

ciated with dysregulated emotions while shaping and

reinforcing more effective, adaptive behaviors. For a

review of DBT in clinical practice, see Dimeff and Koerner

(2007) and Rizvi et al. (2012).

Empirical Outcomes

Numerous randomized controlled trials (RCTs) with

adults have demonstrated DBT’s efficacy in treating BPD

and a range of other psychiatric disorders across various

settings. Reviewed below are RCTs of DBT for adults,

empirical findings from these studies, and proposed

mechanisms of change. To date, standard outpatient DBT

(including all four modes of therapy) for adults with BPD

has been evaluated in nine RCTs, three of which included

adults with BPD plus substance use disorders. Five RCTs

compared DBT with treatment as usual (TAU; Carter

et al. 2010; Koons et al. 2001; Linehan et al. 1991, 1999;

Verheul et al. 2003), while four RCTs compared DBT

with active treatments (Clarkin et al. 2007; Linehan et al.

2002, 2006; McMain et al. 2009). Active comparison

treatments included comprehensive validation with

12-step (Linehan et al. 2002), community treatment by

experts (primarily psychodynamic treatment; Linehan

et al. 2006), transference-focused therapy or supportive

treatment (Clarkin et al. 2007), and general psychiatric

management (psychodynamic treatment plus medication

management; McMain et al. 2009). A recent meta-anal-

ysis including eight RCTs and eight non-RCTs also

examined the efficacy of standard DBT for adults with

BPD (Kliem et al. 2010).

Two recent RCTs of DBT utilized broader inclusion

criteria than BPD diagnosis. One RCT evaluated DBT

versus TAU in an outpatient publicly funded service setting

for adults with any cluster B personality disorder (i.e.,

borderline, antisocial, narcissistic, histrionic; Feigenbaum

et al. 2012). The other RCT evaluated DBT versus opti-

mized TAU (supervision provided by non-cognitive

behavioral expert) in a college counseling center for stu-

dents who were suicidal, reported at least one lifetime

NSSI or suicide attempt, and endorsed three or more BPD

symptoms (Pistorello et al. 2012).

DBT for adults with BPD has also been evaluated

adjunctive to medication (Linehan et al. 2008; Simpson

et al. 2004; Soler et al. 2005). Though these studies were

RCTs, all participants received DBT and only the medi-

cation condition (active medication versus placebo) dif-

fered between groups.

Nine additional RCTs evaluated adapted DBT for adults

with depression, eating disorders (EDs), attention-deficit/

hyperactivity disorder (ADHD), and BD. Rationale for use

of DBT with these disorders rests in the common under-

lying dysfunction in emotion regulation (Kring and Sloan

2010). Two RCTs evaluated DBT plus antidepressant

medication versus antidepressant medication alone for

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

group skills training and telephone coaching (Lynch et al.

2003) or individual therapy and group skills training

(Lynch et al. 2007a). One RCT for treatment-resistant

depression evaluated DBT group skills training versus

waitlist control (WLC; Harley et al. 2008). Two RCTs for

BED evaluated DBT group skills training versus WLC

(Telch et al. 2001) or an active group therapy comparison

(Safer et al. 2010). Two RCTs evaluated individual DBT

(with some skills training review) versus WLC for BN

(Safer et al. 2001) and binge eating and purging episodes

(Hill et al. 2011). One RCT for ADHD evaluated DBT

group skills training versus structured group discussion

control (Hirvikoski et al. 2011). Lastly, one RCT for BD

evaluated DBT group skills training versus WLC (Van Dijk

et al. 2012).

In addition to outpatient settings, where most of the

aforementioned RCTs were conducted, DBT has been

successfully implemented with adults in inpatient units

(e.g., Bohus et al. 2000, 2004; Kröger et al. 2006, 2010),

community mental health centers (e.g., Comtois et al.

2007; Pasieczny and Connor 2011; Prendergast and

McCausland 2007), and forensic settings (e.g., Berzins and

Trestman 2004; Bradley and Follingstad 2003; Evershed

et al. 2003). However, these studies were not RCTs.

Results from RCTs cumulatively suggest that partici-

pation in DBT is associated with: reduced frequency and

severity of suicide behavior and/or NSSI (Carter et al.

2010; Clarkin et al. 2007; Feigenbaum et al. 2012; Koons

et al. 2001; Linehan et al. 1991, 1993, 1999, 2006, 2008;

McMain et al. 2009, 2012; Pistorello et al. 2012; van den

Bosch et al. 2002, 2005; Verheul et al. 2003) and suicide

ideation (Koons et al. 2001; Linehan et al. 2006); decreased

BPD symptoms (McMain et al. 2009, 2012; Pistorello et al.

2012), substance abuse/dependence (Harned et al. 2008;

Linehan et al. 1999, 2002; van den Bosch et al. 2005), ED

symptoms (Hill et al. 2011; Safer et al. 2001, 2010; Telch

et al. 2001), ADHD symptoms (Hirvikoski et al. 2011),

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123

hopelessness (Koons et al. 2001), depression (Clarkin et al.

2007; Feigenbaum et al. 2012; Harley et al. 2008; Koons

et al. 2001; Linehan et al. 2006, 2008; Lynch et al. 2003,

2007a; McMain et al. 2009, 2012; Pistorello et al. 2012;

Simpson et al. 2004; Soler et al. 2005; Van Dijk et al.

2012), anger/irritability (Feigenbaum et al. 2012; Koons

et al. 2001; Linehan et al. 1993, 1994, 1999, 2008; McMain

et al. 2009, 2012), aggression (Linehan et al. 2008; Soler

et al. 2005), and affective control (Van Dijk et al. 2012);

reduced health service utilization and/or inpatient psychi-

atric days (Carter et al. 2010; Koons et al. 2001; Linehan

et al. 1991, 1993, 2006; McMain et al. 2009, 2012; Van

Dijk et al. 2012); and improved social and global adjust-

ment (Clarkin et al. 2007; Feigenbaum et al. 2012; Linehan

et al. 1993, 1994, 1999; Pistorello et al. 2012; Simpson

et al. 2004), treatment retention (Linehan et al. 1991, 1999,

2006; Safer et al. 2010; van den Bosch et al. 2002; Verheul

et al. 2003), quality of life (Carter et al. 2010; McMain

et al. 2009, 2012), and interpersonal functioning (McMain

et al. 2009, 2012).

While all RCTs demonstrated DBT improved emotional

and behavioral symptoms following treatment, some

studies conducted by researchers not affiliated with the

treatment developers (e.g., Carter et al. 2010; Feigenbaum

et al. 2012) and studies that compared DBT with active

treatments (especially treatments specifically designed for

individuals with BPD: Clarkin et al. 2007; McMain et al.

2009, 2012) did not always yield significant between-group

differences. Results from the meta-analysis of standard

DBT for adults with BPD by Kliem et al. (2010) also found

good treatment retention (27.3 % drop-out rate), a moder-

ate global effect size, and a moderate effect size for suicide

and self-injurious behaviors. However, this effect size

decreased to small when DBT was compared with BPD-

specific treatments, and a small reduction in effects was

shown at follow-ups. Thus, numerous studies of DBT for

BPD and other psychiatric disorders in various settings

have yielded positive results and suggest efficacy in

improving various emotional and behavioral symptoms in

adults, though not always to a significantly greater degree

than active treatments.

Though growing evidence supports the efficacy of DBT

for various adult psychiatric disorders, mechanisms of

change and necessary components linked with clinical

improvements are not well understood (Robins and Chap-

man 2004). As aforementioned, most RCTs have evaluated

the efficacy of standard DBT for BPD. However, a recent

RCT demonstrated efficacy of 3 months of DBT group

skills training alone versus psychodynamic-oriented group

skills training control among adults with BPD (Soler et al.

2009). Other RCTs have demonstrated efficacy of group

skills training alone among adults with depression (Harley

et al. 2008; Lynch et al. 2003), BED (Safer et al. 2010;

Telch et al. 2001), ADHD (Hirvikoski et al. 2011), and BD

(Van Dijk et al. 2012). In addition, a recent examination of

mediators in three RCTs of DBT for BPD revealed that

DBT skills fully mediated the decrease in suicide attempts

and depression and the increase in control of anger over

time (Neacsiu et al. 2010). DBT skills also partially med-

iated the decrease in NSSI over time. Efficacy of DBT

group skills training in aforementioned studies supports a

skills deficit model of these psychiatric disorders.

However, some RCTs that evaluated adapted DBT for

other psychiatric disorders found support for individual

therapy alone (with some skills training review) among

adults with BN (Safer et al. 2001) and binge eating and

purging episodes (Hill et al. 2011). In addition, a recent

non-RCT found similar positive outcomes among adults

with BPD who received 1 year of standard DBT versus

individual DBT (with incorporated skills training; Andión

et al. 2012). The role of the therapeutic relationship in DBT

has recently been examined using data from a previous

RCT (Linehan et al. 2006). Specifically, relative to com-

munity treatment by experts, DBT participants developed

significantly greater self-affirmation, self-love, self-pro-

tection, and less self-attack (Bedics et al. 2012a). In addi-

tion, DBT participants who perceived their therapist as

affirming and protecting reported less frequent NSSI.

Support has also been demonstrated for therapists’ bal-

ancing of autonomy and control, maintaining a non-

pejorative stance, and using warmth and autonomy (Bedics

et al. 2012b). These studies support the importance of

individual therapy components in DBT (e.g., behavior

therapy strategies, combination of acceptance and change

interventions, dialectical strategies, nonjudgmental

assumptions about patients) and the quality of the thera-

peutic relationship in ensuring positive clinical outcomes.

Thus, while additional research is needed to examine the

utility of specific treatment modes and strategies and their

role in the efficacy of DBT, results from RCTs support the

use standard DBT for adults with BPD, with growing

evidence for adaptations of DBT for other psychiatric

disorders.

Dialectical Behavior Therapy for Adolescents

Given positive outcomes with adults, recent research has

adapted and evaluated DBT for adolescents. The follow-

ing section reviews the theoretical underpinnings

informing use of DBT with adolescents, summarizes

treatment adaptations originally proposed by Miller et al.

(1997, 2007b), and concludes with a review of empirical

studies of DBT for adolescents. Limitations of current

studies and considerations for future research are also

discussed.

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Theory

As reviewed above, DBT has been found to be efficacious

for adults with BPD (www.div12.org/Psychological

Treatments/treatments/bpd_dbt.html). Thus, adaptation of

DBT for adolescents with BPD symptoms or diagnosis may

be warranted and beneficial. Though most evaluations of

DBT for adolescents have included youth with BPD fea-

tures, other studies have targeted youth with various psy-

chiatric disorders (i.e., mood disorders, externalizing

disorders, EDs, TTM) and problem behaviors (i.e., suicide

ideation and behavior, NSSI) across several settings (i.e.,

outpatient, day program, inpatient, residential, correctional

facility). The rationale for using DBT with these adoles-

cents rests in the common underlying dysfunction in

emotion regulation among the aforementioned disorders

and problem behaviors.

Most adolescent DBT studies targeted youth with BPD

features (Fleischhaker et al. 2011; James et al. 2008, 2011;

Miller et al. 2000; Rathus and Miller 2002; Woodberry and

Popenoe 2008). Though somewhat controversial, research

suggests that the prevalence, reliability, and validity of

BPD diagnoses in adolescent samples are largely compa-

rable to those found among adult samples (Miller et al.

2008). Adolescents with BPD present with similar symp-

toms and functional impairment as adults with BPD

(Becker et al. 2002; Chanen et al. 2007). However,

research on the stability of BPD over time is mixed. While

for some severely affected adolescents the diagnosis of

BPD remains stable over time, a less severe subgroup of

youth moves in and out of diagnosis (Miller et al. 2008).

These findings are consistent with research suggesting that

BPD diagnostic status in adults is not particularly stable

(Zanarini et al. 2010). Symptoms related to temperament,

such as abandonment fears, have higher positive predictive

power when making the diagnosis of BPD in adolescents

(Becker et al. 2002) and also endure longer than other BPD

symptoms (e.g., those related to impulsivity) in adult

samples (Zanarini et al. 2007). Thus, research indicates that

the diagnosis of BPD in adolescents is comparable in terms

of symptom constellation, functional impairment, and

temporal stability to the diagnosis when made in adult

samples. Therefore, adaptation of DBT, an evidence-based

treatment for adults with BPD, for adolescents who exhibit

BPD features or diagnosis is a logical extension.

Although most empirical studies of DBT have included

adults with BPD, DBT was originally developed to treat

suicide-related behavior and extreme emotional and

behavioral dysregulation (Robins and Rosenthal 2011). As

such, within the DBT framework, BPD is conceptualized

primarily as a disorder of emotion regulation. Problematic

behaviors are viewed as efforts to regulate extreme emo-

tions or consequences of failed emotion regulation

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

with similar dysregulated emotions and problematic

behaviors, and emotion dysregulation has been linked with

the development of various forms of psychopathology in

adolescents (McLaughlin et al. 2011), extension of DBT to

a broader group of adolescents (as opposed to just those

with BPD) may be warranted.

All of the behaviors and disorders that have been tar-

geted in studies of DBT for adolescents can be conceptu-

alized by poor emotion regulation. For example, all

evaluations of adolescents with BPD features (Fleischhaker

et al. 2011; James et al. 2008, 2011; Miller et al. 2000;

Rathus and Miller 2002; Woodberry and Popenoe 2008)

and one study of hospitalized adolescents (Katz et al. 2004)

also incorporated suicide ideation, suicide behavior, and/or

NSSI as study inclusion criteria. Indeed, suicide ideation

(Orbach et al. 2007), suicide behavior (Tamás et al. 2007;

Zlotnick et al. 1997), and NSSI (Adrian et al. 2011; Nock

and Prinstein 2004; Nock et al. 2009) have been shown to

be related to emotion dysregulation in youth. For example,

the most common self-reported reasons for adolescent

NSSI are automatic positive reinforcement (i.e., to create a

desirable physiological state) and automatic negative

reinforcement (i.e., to escape from an averse physiological

state; Nock and Prinstein 2004; Nock et al. 2009). In

addition, the automatic negative reinforcement function of

NSSI has been associated with a history of suicide attempts

in adolescents (Nock and Prinstein 2005), thus supporting

an emotion regulation function of suicide ideation, suicide

behavior, and NSSI in adolescents.

Adaptations of DBT for youth with ODD (Nelson-Gray

et al. 2006), BD (Goldstein et al. 2007), BED (Safer et al.

2007), AN (Salbach-Andrae et al. 2008), BN (Salbach-

Andrae et al. 2008), and TTM (Welch and Kim 2012) can

also be tied to a common underlying dysfunction in emo-

tion regulation. For example, the diagnostic criteria for

ODD include emotion dysregulation (e.g., often loses

temper, spiteful and vindictive), interpersonal difficulties

(e.g., argues with adults, annoys others on purpose), and

poor distress tolerance (e.g., easily annoyed, angry and

resentful; Nelson-Gray et al. 2006). In addition, early

emotion dysregulation has been linked with the develop-

ment of ODD (Stingaris et al. 2010), while recent research

suggests that early ADHD and ODD symptoms predict

subsequent development of BPD symptoms (Burke and

Stepp 2012; Stepp et al. 2012). Similarly, research posits

that the core feature of adolescent BD is emotion dysreg-

ulation (Carlson and Meyer 2006; Dickstein and Leibenluft

2006; Leibenluft et al. 2003). In addition, BD in adoles-

cents is associated with suicide behavior (Goldstein et al.

2005), NSSI (Esposito-Smythers et al. 2010), interpersonal

deficits (Goldstein et al. 2006), and treatment noncompli-

ance (Coletti et al. 2005), all of which are DBT targets, and

Clin Child Fam Psychol Rev (2013) 16:59–80 69

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DBT has been successfully implemented with adults with

BD in a recent RCT with promising results (Van Dijk et al.

2012). Thus, both ODD and BD in adolescents are asso-

ciated with dysfunction in emotion regulation as well as

other problem behaviors targeted in and responsive to

DBT.

Emotion dysregulation has also been linked to EDs and

TTM. Regarding EDs, an adapted biosocial theory posits

that EDs develop through transaction between an invali-

dating environment and a biological vulnerability to reg-

ulating emotions and/or to the hunger/satiety system

(Wisniewski and Kelly 2003; Wisniewski et al. 2007). ED

behaviors (bingeing, purging, restricting) are viewed as

behavioral attempts to avoid painful emotions, in the case

of AN, or change painful emotions, in the case of BED and

BN. Some empirical evidence also supports the role of

emotion dysregulation in ED symptoms in youth (Sim and

Zeman 2005). In addition, adolescents with EDs commonly

present with suicide ideation, suicide behavior, and NSSI,

which are targets in DBT (Bjarehed and Lundh 2008;

Peebles et al. 2011; Ruuska et al. 2005). Also, DBT has

been adapted for adults with EDs and demonstrated posi-

tive results in RCTs (Hill et al. 2011; Safer et al. 2001,

2010; Telch et al. 2001). Regarding TTM, research with

adults and youth indicates hair pulling is automatic/habit-

ual or functions to regulate emotions, with the latter cued

by negative emotions, intense thoughts or urges, or

attempts to create symmetry (Christenson and Mackenzie

1994; Diefenbach et al. 2008; Flessner et al. 2007, 2008,

2009; Shusterman et al. 2009). Also, DBT has been

adapted for adults with TTM and demonstrated promising

results in a case study (Keuthen and Spirch 2012) and open

trial (Keuthen et al. 2010, 2011). Thus, EDs and TTM in

adolescents are associated with emotion dysregulation and

problem behaviors targeted in DBT, and studies of DBT for

adults with EDs and TTM demonstrated positive findings.

Some researchers have investigated DBT for adoles-

cents in particular settings with a transdiagnostic focus

rather than targeting certain psychiatric disorders or

behavioral problems. Specifically, DBT has been imple-

mented with youth in correctional facilities (Shelton et al.

2011; Trupin et al. 2002), residential treatment facilities

(Sunseri 2004; Wasser et al. 2008), long-term inpatient

units (McDonell et al. 2010), and day treatment programs

(Charlton and Dykstra 2011). Again, rationale for using

DBT with these adolescents is based on the underlying

dysfunction in behavioral and emotional regulation. Youth

who participated in DBT in aforementioned studies pre-

sented with a number of psychiatric diagnoses (e.g., BPD,

substance abuse/dependence, EDs, mood disorders, post-

traumatic stress disorder, ADHD, ODD, conduct disorder)

and impairing behaviors (e.g., suicide ideation and

behavior, NSSI, aggression, impulsivity, disruptive

behavior, running away). Therefore, DBT in these settings

is applied transdiagnostically with the aim of reducing the

myriad symptoms related to behavioral and emotional

dysregulation and that have demonstrated improvement in

adult RCTs of DBT.

Thus, DBT has been adapted for adolescents with BPD,

suicide ideation and behavior, NSSI, ODD, BD, EDs, and

TTM. DBT has also been implemented in diverse settings

with youth who present with varied psychiatric and

behavioral impairment. Rationale for initiating DBT with

these adolescents rests in the common problems in emotion

regulation. Linehan (1993a) conceptualized BPD as a dis-

order of emotion regulation in the initial development of

the treatment, and as such, DBT is comprehensive and

flexible in a way that allows for use with clients presenting

with varied diagnoses, in diverse settings, across a rela-

tively larger age range.

Treatment Adaptations

Miller et al. (1997, 2007b) were the first to propose

adaptations of DBT for adolescents and subsequently

developed a treatment manual. Their adaptations targeted

youth exhibiting suicide ideation and behavior, NSSI, and

BPD features. Subsequent adaptations for other adolescent

presenting problems are modeled after and closely resem-

ble the Miller et al. (2007b) manual. DBT for adolescents

generally follows the same format as standard DBT,

including theoretical framework, functions, treatment tar-

gets, treatment modes, and strategies (Klein and Miller

2011). However, Miller et al. (2007b) introduced modifi-

cations to make DBT more developmentally appropriate

for adolescents and their families. The following summary

provides an overview of the adaptations to DBT for ado-

lescents, as delineated in the DBT manual for suicidal

adolescents by Miller et al. (2007b).

DBT for adolescents includes seven main adaptations of

standard DBT. First, family members, usually parents, are

included in multifamily skills training groups to enhance

generalization and reinforcement of skills and structure

adolescents’ environments (Miller et al. 2007a). In this

way, parents can serve as models and coaches for their

adolescents by utilizing and implementing skills. Parental

participation in skills training is designed to provide a

common vocabulary for therapeutic techniques within

families and enhance parents’ ability to provide validation,

support, and effective parenting. Including family members

in skills groups also offers the added benefits of providing

in vivo opportunities to role play skills, fostering inter-

family support, reducing adolescents’ disruptive behaviors

in group, and enhancing treatment compliance. Family

members may also receive telephone coaching and con-

sultation from the skills group therapist for skills

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

123

generalization, while adolescents receive telephone

coaching from the primary individual therapist (Steinberg

et al. 2011).

Second, family therapy sessions are conducted on an

as-needed basis. Although individual sessions with sig-

nificant others are incorporated into standard DBT for

adults, adapted DBT for adolescents focuses more

explicitly on this mode of treatment (Miller et al. 2002;

Woodberry et al. 2002). Family therapy sessions were

added because much of the turmoil in the lives of suicidal

adolescents involves their primary support system. Family

sessions are conducted when the relationship with a

family member is a central source of conflict or when a

crisis erupts within the family. The therapist may also

initiate family sessions if the treatment would be

enhanced by educating family members about particular

skills or aspects of treatment or if contingencies in the

home are too powerful for the adolescent to ignore and

continue to reinforce dysfunctional behavior. Goals of

family sessions include preparing the adolescent for

family interactions, increasing parental understanding of

adolescent’s emotional vulnerability, addressing parents’

own emotion dysregulation, improving familial commu-

nication, modifying contingencies in the familial envi-

ronment, and crisis management. Typically, selected

family members will attend 3 to 4 sessions out of the

adolescent’s 16 weeks of individual therapy, though more

or fewer sessions can be scheduled as needed.

A third adaptation involves the development and

teaching of three adolescent–family dialectical dilemmas

(Rathus and Miller 2000). Similar to the original dialectical

dilemmas proposed by Linehan (1993a), these adolescent–

family dialectical dilemmas are considered secondary

behavioral targets in DBT. The first dialectical dilemma,

excessive leniency versus authoritarian control, involves

placing too few behavioral demands or limits on the ado-

lescent, or being excessively permissive, versus enacting

coercive parenting methods limiting freedom, autonomy,

and independence. Normalizing pathological behaviors

versus pathologizing normative behaviors, the second

dialectical dilemma, involves viewing developmentally

normal adolescent behaviors as deviant versus failing to

address or perceive deviant adolescent behaviors as such.

Lastly, forcing autonomy versus fostering dependence

involves acting in ways that inhibit an adolescent’s

autonomy (e.g., excessive caretaking, overreliance on

parents) versus parents’ severing ties with the adolescent

such that he or she is prematurely forced to separate and

become self-sufficient. Adolescents and families tend to

vacillate between these polarities, causing extreme distress.

Thus, the central dilemma of treatment is to help adoles-

cents and parents move to a balanced position representing

synthesis.

Fourth, the treatment length was reduced from 1 year to

16 weeks. This may be the biggest change from standard

DBT because the time in treatment is significantly reduced

but the content (e.g., dialectical dilemmas, skills training

modules) is increased. According to Miller et al. (2007b),

treatment length was modified so it would be more

appealing to adolescents, given that suicidal adolescents

tend to complete only a limited number of therapy sessions.

For example, up to 77 % of adolescents who attempt sui-

cide do not attend therapy appointments or fail to complete

treatment (Trautman et al. 1993). Also, Miller et al.

(2007b) aimed to offer a brief treatment because they were

including many clients with first-time NSSI or suicide

attempts, many of whom did not meet full criteria for BPD.

Thus, they believed they could treat many of these ado-

lescents with a short-term treatment and offer optional

additional therapy (i.e., a graduate group or repeat of first

phase of treatment) for those who continued to exhibit

behavioral dyscontrol. Treatment length was also reduced

for pragmatic concerns so that clients who could not afford

extended therapy could still receive meaningful treatment,

which was in line with the current healthcare climate (e.g.,

acceptable to insurance companies).

A fifth adaptation, also involving the structure of DBT,

is a second phase of treatment: a 16 week optional graduate

group (with other treatment modes utilized as needed) for

clients who continue to exhibit difficulties following the

first phase of therapy (Miller et al. 2007a). Youth may

repeat the graduate group as many times as necessary in

order to achieve their identified goals. Both phases of

treatment address only the DBT stage one targets of

reducing life-threatening behaviors, reducing therapy-

interfering behaviors, reducing quality-of-life-interfering

behaviors, and increasing behavioral skills. The graduate

group is designed to address the DBT treatment functions

of improving capabilities, improving motivation, and pro-

moting generalization of skills, but in a way that requires

less intensive adolescent participation and fewer program

resources. The goal of the graduate group is to reinforce

and generalize skills previously taught. Group sessions

involve adolescents reviewing and teaching skills to peers

and consulting and problem solving with group members to

foster peer coaching and support rather than reliance on the

therapist. During this phase, the therapist consultation team

also continues, addressing the functions of treating the

therapist and structuring the environment as needed.

Continuing treatment in a separate, second phase with

reduced intensity allows for clients to feel an increased

sense of mastery without removing structural resources that

may be helping to maintain progress. Further, increasing

the length of treatment with a graduate group offers ado-

lescent clients the opportunity to use the skills that they

learned in the first stage of treatment to broaden treatment

Clin Child Fam Psychol Rev (2013) 16:59–80 71

123

goals once skills acquisition has occurred. Importantly, this

two-stage approach allows for reallocating staff resources

to ensure that therapists are available for more intensive

treatment of new clients who are beginning DBT.

Sixth, the number of skills taught within each module

was slightly reduced and a fifth adolescent-specific skills

module was added. Most of the original DBT skills were

maintained because there is no theoretical or empirical

basis for which skills to include or eliminate. In addition to

the four original DBT skills modules (i.e., mindfulness,

interpersonal effectiveness, emotion regulation, distress

tolerance), a fifth skills module, walking the middle path,

was developed for adolescents and their families. This

module teaches validation of self and others, behavioral

principles (i.e., how to reinforce, extinguish, punish, and

shape behavior), and three adolescent–family dialectical

dilemmas (described above) with the goal of finding the

middle path, or balanced synthesis, in each dilemma. The

dialectical dilemmas are introduced in the multifamily

skills training groups and are targeted in individual and

family therapy sessions.

Lastly, group skills handouts were modified to improve

their appeal and applicability to adolescents. Modifications

include simplification of terminology, streamlined language,

simplification of visual layout to decrease visual overstim-

ulation (via reduced amount of variability in font size, bold

print, underlining, and italicizing), and addition of adoles-

cent-geared graphics. Other important modifications when

teaching skills include adapting examples of each skill to

make them more applicable to adolescents and utilizing more

experiential and in vivo, rather than didactic, methods.

Thus, DBT for adolescents is based on the same theo-

retical underpinnings and generally follows the same

framework, including functions of treatment, targets,

modes, and strategies, as standard DBT for adults. How-

ever, adaptations involving inclusion of family members in

skills training, addition of family therapy sessions, devel-

opment of new adolescent–family dialectical dilemmas,

reduction of treatment length, addition of an optional

graduate group, implementation of a new skills module,

and modifications to handouts and delivery of content in

skills groups make DBT more applicable and appealing to

adolescents and their families.

Empirical Outcomes

To date, DBT for adolescents has been evaluated in 18

studies published in English-language journals. First, six

studies that targeted youth with BPD features plus suicide

ideation, suicide behavior, and/or NSSI (Fleischhaker et al.

2011; James et al. 2008, 2011; Miller et al. 2000; Rathus

and Miller 2002; Woodberry and Popenoe 2008) and one

study that targeted adolescents hospitalized for suicide

ideation or attempt (Katz et al. 2004) are reviewed. Then,

five studies that adapted DBT for other diagnoses associ-

ated with emotion dysregulation are summarized; specifi-

cally, one study each of youth with ODD (Nelson-Gray

et al. 2006), BD (Goldstein et al. 2007), BED (Safer et al.

2007), both AN and BN (Salbach-Andrae et al. 2008), and

TTM (Welch and Kim 2012). Lastly, six studies that

investigated DBT for adolescents in diverse settings rather

than with specific psychiatric or behavioral problems are

reviewed; including, correctional facilities (Shelton et al.

2011; Trupin et al. 2002), residential treatment centers

(Sunseri 2004; Wasser et al. 2008), long-term inpatient

units (McDonell et al. 2010), and day treatment programs

(Charlton and Dykstra 2011). See also Groves et al. (2012)

for a review of the adolescent DBT outcome literature

through 2008. The review concludes with a discussion of

limitations of current research and considerations for future

directions.

Five open trials of DBT for adolescents with BPD

symptoms plus suicide ideation, suicide behavior, and/or

NSSI demonstrated positive results (Fleischhaker et al. 2011;

James et al. 2008, 2011; Miller et al. 2000; Woodberry and

Popenoe 2008; see Table 1). These studies were conducted

predominantly with females in outpatient or community

clinic settings and most closely followed the DBT for ado-

lescents manual (including all four modes of standard DBT

plus family involvement; Miller et al. 2007b), aside from

variations in treatment length (ranging from 12 weeks

to 1 year). Results indicated improvements in suicide idea-

tion (Woodberry and Popenoe 2008), suicide behavior

(Fleischhaker et al. 2011), NSSI (Fleischhaker et al. 2011;

James et al. 2008, 2011), thoughts of NSSI (Woodberry and

Popenoe 2008), BPD symptoms (Fleischhaker et al. 2011;

Miller et al. 2000), depressive symptoms (James et al. 2008,

2011; Woodberry and Popenoe 2008), hopelessness (James

et al. 2008, 2011), dissociative symptoms (Woodberry and

Popenoe 2008), anger (Woodberry and Popenoe 2008),

overall psychiatric symptoms (Fleischhaker et al. 2011;

Woodberry and Popenoe 2008), general functioning (James

et al. 2008, 2011; Woodberry and Popenoe 2008), and psy-

chosocial adjustment (Fleischhaker et al. 2011). High com-

pletion rates were also reported (63–87.5 %), and in one

study, adolescents rated all skills moderately to extremely

helpful (Miller et al. 2000). Two studies demonstrated

maintenance of gains over 8-month (James et al. 2008)

and 1-year (Fleischhaker et al. 2011) follow-ups. Interest-

ingly, Woodberry and Popenoe (2008) also found signifi-

cant posttreatment improvement in parents’ depressive

symptoms.

Similarly, two quasi-experimental studies (i.e., lacking

random assignment) indicated improvement following

DBT when compared with TAU (psychodynamic psycho-

therapy) for mostly female adolescents with BPD features

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

123

plus suicide ideation or recent suicide attempt (Rathus and

Miller 2002) and adolescents hospitalized on an inpatient

unit for suicide ideation or attempt (Katz et al. 2004; see

Table 1). Rathus and Miller (2002) implemented DBT in

an outpatient setting and closely followed the Miller et al.

(2007b) manual; however, Katz et al. (2004) made adap-

tations to frequency of treatment modes to make DBT more

applicable on an inpatient unit (also, telephone coaching

was not used). Rathus and Miller (2002) found adolescents

who received 12 weeks of DBT demonstrated significantly

fewer psychiatric hospitalizations (0 versus 13 %) and

higher treatment completion (62 versus 40 %) compared

with TAU, despite youth in the DBT group having sig-

nificantly more psychopathology at baseline (i.e., depres-

sive and substance use disorders and BPD). There were no

significant between-group differences in suicide attempts,

likely due to low occurrence in both groups (7.3 %),

though only one DBT participant made an attempt during

the study versus seven in TAU. DBT participants also

demonstrated significant reductions in suicide ideation,

depression, anxiety, general psychiatric symptoms, global

severity, and BPD symptoms posttreatment; however, these

were not measured in the TAU group and thus could not be

compared. Katz et al. (2004) found adolescents who

received 2 weeks of DBT demonstrated a significant

reduction in the number of incidents on the inpatient unit

(e.g., violence toward self and others) when compared to

TAU at posttreatment. In addition, there was a significant

reduction in total number of incidents on the unit when

comparing the 6-month period before and after DBT

implementation. Both groups also demonstrated significant

reductions in NSSI, depression, and suicide ideation over

1-year follow-up.

Studies of DBT for ODD, BD, EDs, and TTM in out-

patient settings similarly demonstrated promising results;

however, these adaptations deviated significantly from the

Miller et al. (2007b) manual and lacked control compari-

sons (see Table 2). An open trial of 16 weeks of adoles-

cent-only group skills training with adaptations to improve

compliance (e.g., pizza, financial incentives) for youth with

ODD (mostly males) found significant posttreatment

improvements in positive behaviors (i.e., interpersonal

strength), ODD and externalizing behaviors, depressive

symptoms, internalizing symptoms, and total problem

behaviors (Nelson-Gray et al. 2006). An open trial of

1 year of DBT for youth (mostly females) with BD con-

sisting of acute treatment and continuation phase with BD

adaptations (e.g., psychoeducation about BD) and indi-

vidual therapy, individual family skills training, and tele-

phone coaching demonstrated high completion and

satisfaction and significant improvements in suicide idea-

tion, emotion dysregulation, and depression, and nonsig-

nificant improvement in NSSI (Goldstein et al. 2007).

One case study and one case series of DBT for youth

with EDs and one case study of DBT for an adolescent with

TTM also provide support for DBT with these populations

(see Table 2). DBT for adolescents with EDs incorporated

adaptations, such as reviewing the DBT model of disor-

dered eating behaviors and their association with dysreg-

ulated emotions, providing nutrition psychoeducation,

dispelling myths about food, and addressing negative body

issues. A case study of a 16-year-old female with BED who

received 21 weeks of individual therapy (with incorporated

skills review), 4 family therapy sessions, and telephone

coaching demonstrated reduced frequency and severity of

binge episodes posttreatment and at 3-month follow-up

(Safer et al. 2007). A case series of 25 weeks of DBT for

females with AN or BN consisting of weekly individual

therapy and adolescent group skills training (parents

attended 8 groups), telephone coaching, and consultation

team meetings found high treatment completion and sig-

nificant posttreatment improvements in behavioral symp-

toms of eating disorders (i.e., restricting, bingeing,

purging) and general psychopathology; AN youth also

demonstrated significant improvement in body mass index

(Salbach-Andrae et al. 2008). A case study of 16 weeks of

DBT for a 15-year-old female with TTM consisting of

weekly individual therapy with parent check-ins, psycho-

education about TTM, self-monitoring, chain analyses,

habit reversal, stimulus control, relapse prevention, and

DBT skills (mindfulness, emotion regulation, distress tol-

erance) found improvements in hair pulling, emotion reg-

ulation, anxiety, and depression by posttreatment, with

slight worsening of hair pulling at follow-up (Welch and

Kim 2012).

Further lending support to the use of DBT with ado-

lescents are six studies that adapted and examined DBT for

youth in specific settings (i.e., correctional facilities, resi-

dential treatment centers, long-term inpatient units, day

treatment programs) rather than with particular psychiatric

or behavioral targets, though many of these youth pre-

sented with numerous and severe psychiatric and behav-

ioral problems (see Table 3). These studies used open

designs, uncontrolled groups, or examination of time

periods before and after DBT implementation. DBT

adaptations also significantly deviated from the DBT for

adolescents manual (Miller et al. 2007b). Two studies in

correctional facilities implemented adolescent-only group

skills training in either a pre–post design with TAU control

and all females over 10 months (Trupin et al. 2002) or an

open design with males over 16 weeks (Shelton et al.

2011). Results indicated improvements in: behavior prob-

lems (e.g., aggression, NSSI, classroom disruption) and

punitive responses (Trupin et al. 2002); and coping,

aggression, impulsive behaviors, negative affect, and self-

control (Shelton et al. 2011). Two studies in residential

Clin Child Fam Psychol Rev (2013) 16:59–80 73

123

treatment facilities implemented either all four modes of

treatment over 29 months with females (compared

29 months before and after DBT implementation; Sunseri

2004) or individual therapy plus multifamily group skills

training over 17 weeks with mostly males and matched

standard therapeutic milieu control (STM; Wasser et al.

2008). Results demonstrated significant reductions in pre-

mature terminations due to self-harm or psychiatric hos-

pitalization (16.7 versus 0 %), number of days clients spent

in psychiatric hospitals due to NSSI (71 inpatient days

from 8 clients versus 42 inpatient days from 6 clients), and

duration of physical restraints and seclusions (median of

20 min versus 11 min) following implementation of DBT

(Sunseri 2004); and improvement in general psychiatric

symptoms, with DBT having a significantly greater impact

on depression and STM having a significantly greater

impact on psychomotor excitation (Wasser et al. 2008).

McDonell et al. (2010) compared youth receiving DBT

in a long-term inpatient unit to historical controls (who

received individual and family therapy as needed) over

1 year with three levels of DBT intensity (i.e., DBT milieu,

DBT milieu plus group skills training, or DBT milieu plus

group skills training and individual therapy) and found

significant improvement in global functioning and signifi-

cant reduction in number of medications, and significant

reduction in NSSI compared with control. Finally, exami-

nation of 19 months DBT adapted for youth with devel-

opmental and behavioral health needs in a day treatment

program (i.e., individual therapy, group skills training,

consultation team, telephone coaching, milieu behavior

management) found increased DBT skills use, ability to

identify maladaptive emotions, thoughts, and actions, and

significant correlation between problem behaviors (e.g.,

argued, tried to avoid work, tried to hurt self or others,

attempted suicide), negative thoughts, and negative feel-

ings with month (i.e., as number of months in DBT

increased number of problem behaviors, negative thoughts,

and negative feelings decreased; Charlton and Dykstra

2011). Collectively, findings from pre–post, uncontrolled,

and quasi-experimental studies examining DBT for ado-

lescents with a range of psychiatric disorders and problem

behaviors in various settings have yielded promising

results.

Limitations

Despite advances in research on DBT for adolescents,

significant limitations exist. First, although DBT was

originally adapted for adolescents with BPD features and

suicide ideation, suicide behavior, and/or NSSI, only five

open studies and one quasi-experimental trial have exam-

ined the efficacy of DBT for this population. One quasi-

experimental study also evaluated DBT for hospitalized

adolescents with suicide ideation or attempt. Open trials

lacked comparison groups; thus, it is possible that

improvements were due to nonspecific therapeutic factors,

uncontrolled medication use, passage of time, or other

factors unrelated to DBT. Quasi-experimental studies used

TAU control comparisons (psychodynamic psychotherapy)

but lacked random assignment. Thus, systematic differ-

ences between groups may have existed pretreatment and

affected outcome. Indeed, Rathus and Miller (2002) noted

youth who received DBT in their study presented with

significantly greater psychopathology than in the TAU

group.

Studies of DBT for youth with other psychiatric disor-

ders or in specific settings are promising but also have

limitations. First, trials of DBT for ODD and BD were

evaluated via open trials, while adaptations of DBT for

BED and TTM were evaluated in case studies, and DBT for

AN and BN was evaluated in a case series. Lack of com-

parison conditions in these trials limits the conclusions that

can be made about the efficacy of DBT for these disorders

(i.e., improvements may be due to factors unrelated to

DBT). Second, six studies that examined implementation

of DBT for adolescents in specific settings (i.e., correc-

tional facilities, residential treatment centers, long-term

inpatient units, day treatment programs) did not specify

diagnostic or behavioral inclusion criteria. Though these

youth presented with comorbid conditions and significant

impairment, this design creates a heterogeneous sample of

youth with a range of psychiatric and behavioral problems,

some of which may be more responsive to DBT than

others. Also, although four of these studies utilized com-

parison conditions (i.e., pre–post intervention records with

TAU comparison, matched samples across agencies, his-

torical controls, and time periods before and after DBT

implementation), groups were uncontrolled and random

assignment was not used; thus, systematic group differ-

ences may have affected outcome.

Other limitations common to most aforementioned

studies of DBT for adolescents included relatively small

sample sizes consisting mostly of females. Though

McDonell et al. (2010) included 210 youth in their examina-

tion of DBT in a long-term inpatient unit (n = 106) versus

historical controls (n = 104), among outpatient imple-

mentations of DBT with adolescents, which is the recom-

mended form of treatment delivery outlined in both adult

(Linehan 1993a, b) and adolescent (Miller et al. 2007b)

manuals, sample sizes ranged from 1 to 111 (though of

N = 111, only 29 received DBT and 82 received TAU).

Some studies went to great lengths to improve compliance

and retention (e.g., financial incentives, meals, outreach

strategies; James et al. 2011; Nelson-Gray et al. 2006;

Woodberry and Popenoe 2008), which limits the ecological

validity and generalizability of these findings. Also, most

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

123

measures assessed symptoms and functioning through

adolescent self-report. Treatment fidelity was not specifi-

cally measured in any study and treatment length ranged

from 2 weeks to 29 months, with some adaptations devi-

ating considerably from the format and structure of DBT

outlined in manuals (Linehan 1993a, b; Miller et al.

2007b). In addition, only five studies included follow-up

data, and during these periods, treatment was uncontrolled.

Lastly, most trials either did not report medication use, or

this was uncontrolled. As a result of these deviations in

terms of treatment format, structure, and content, the dif-

ferent adolescent psychiatric disorders and problem

behaviors to which DBT was applied, and various study

designs and lengths of follow-up assessments, it is difficult

to synthesize and draw overarching conclusions about the

research on DBT for adolescents.

Future Directions

Given limitations of current studies examining DBT for

adolescents, additional research is needed. Research on

DBT for adolescents is relatively limited (18 studies pub-

lished in English-language journals), and to date, there are

no published RCTs. Given that the RCT design is the gold

standard for determining treatment efficacy (Chambless

et al. 1996, 1998; Chambless and Hollon 1998), multiple

RCTs are needed to evaluate whether DBT can be con-

sidered efficacious for adolescents. Currently, RCTs

examining DBT for adolescents are underway, the results

of which will direct the future of adolescent DBT research

considerably (Groves et al. 2012). Stringent RCTs

employing control comparisons similar to those used in

adult efficacy studies (i.e., starting with WLC or TAU

comparisons, followed by nonbehavioral active treatment

controls) would provide more definitive evidence for the

efficacy of DBT for adolescents. Such RCTs should also be

conducted by diverse research groups, measure and dem-

onstrate adherence to the manual, consider allegiance

effects, include semistructured assessment of adolescent

psychiatric symptoms, and assess functioning at long-term

follow-ups.

Because current empirical evidence is strongest for

adults and adolescents with BPD features plus suicide

ideation, suicide behavior, and/or NSSI, RCTs should first

target youth with these symptoms and behaviors. If efficacy

is demonstrated, additional RCTs examining different

disorders in adolescents with an underlying emotion reg-

ulation dysfunction could be initiated. Similarly, studies in

diverse settings should aim to create more homogenous

samples of youth with similar presenting problems and

defined inclusion/exclusion criteria to test the efficacy of

DBT for a specific disorder or problem behavior. Also,

before mediator, moderator, dismantling, effectiveness, or

dissemination studies are conducted, RCTs are needed to

determine for which adolescent disorders or problem

behaviors DBT is effective.

Miller et al. (2007b) provided a theoretically sound and

developmentally appropriate adaptation of DBT for sui-

cidal adolescents. Future research should aim to evaluate

clinical components and outcomes of this adaptation. For

example, optimal length of treatment should be investi-

gated empirically. Current studies rely on adaptations of

DBT with various lengths, ranging from 2 weeks to

29 months. Though the original manual (Miller et al.

2007b) called for 16 weeks of outpatient treatment with

optional continuation, adolescents with different presenting

problems or in different settings may benefit from alternate

lengths of treatment. In contrast, 16 weeks may indeed be

the optimal length of DBT for adolescents. Empirical

evaluation would provide a more definitive answer to this

question. In addition, evaluation of the most pertinent and

effective DBT components and skills for adolescents and

their families should be considered. Most of the original

DBT treatment modes and skills were maintained in the

adolescent DBT manual (Miller et al. 2007b) because there

is no theoretical or empirical basis for which components

to include or eliminate. However, some adaptations of

DBT for adolescents only included some of the treatment

strategies, modes, and skills. Similarly, particular skills

may be more effective than others for adolescents and their

families. Determination of the most pertinent treatment

components and skills may indicate specific strategies,

modes, and modules to emphasize, which would be espe-

cially informative since treatment of adolescents is typi-

cally much shorter in duration than the original DBT

protocol.

Conclusion

Given positive outcomes among adults with various psy-

chiatric and behavioral impairments, DBT has been adap-

ted for use with adolescents who present with similar

problems. Current adaptations of DBT target youth with

BPD features, suicide ideation and behavior, NSSI, ODD,

BD, EDs, and TTM. DBT has also been applied transdi-

agnostically among youth with varied psychiatric and

behavioral problems in correctional facility, residential,

long-term inpatient, and day treatment settings. Rationale

for using DBT with these adolescents rests in the common

underlying dysfunction in emotion regulation across ages,

diagnoses, and problem behaviors. Treatment adaptations

and length vary depending on the presenting problem and

setting. However, most adaptations are modeled after the

adolescent DBT manual (Miller et al. 2007b) and involve

inclusion of family members in skills training, addition of

Clin Child Fam Psychol Rev (2013) 16:59–80 75

123

family therapy sessions, inclusion of new adolescent–

family dialectical dilemmas, reduction of length of treat-

ment, addition of optional graduate group, implementation

of a new skills module, and modifications to handouts and

delivery of content in skills groups.

Although DBT for adolescents has been examined in

several studies, the research is still in its infancy. Quasi-

experimental studies demonstrated that, when compared

with TAU, DBT for adolescents was associated with sig-

nificant reductions in inpatient hospitalizations, attrition,

and behavioral incidents (e.g., violence toward self and

others). These studies also found DBT was associated with

significant reductions in suicide ideation, NSSI, BPD

symptoms, depression, anxiety, general psychiatric symp-

toms, and global severity, but improvements in these areas

were either not compared with adolescents receiving TAU

(Rathus and Miller 2002) or significant in both DBT and

TAU groups (Katz et al. 2004). Additional findings from

trials using less rigorous methodology demonstrated that

DBT was associated with significant reductions in disso-

ciative symptoms, ED symptoms, TTM symptoms, anger,

externalizing behaviors, impulsivity, hopelessness, emo-

tion dysregulation, general psychopathology, and medica-

tion usage, and significant improvements in interpersonal

strength, coping, general functioning, and psychosocial

adjustment. Thus, DBT appears to be a promising inter-

vention for adolescents presenting with a broad array of

emotion regulation difficulties; however, RCTs are sorely

needed to provide more definitive evidence for the efficacy

of DBT for adolescents.

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