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Dialectical Behaviour Therapy

For youth who self-harm

Lisa C. Vettese, PhD, CPsych

Reprinted from "Treatment for Young People" issue of Visions Journal, 2006, 3 (1), p. 27-28

Teenagers who self-harm deliberately injure or hurt themselves, often in an attempt to cope with overwhelming emotional pain. Examples of self-harm include self-hitting, cutting, scratching, burning and poisoning. Self-harm usually starts during puberty and adolescence, with a high number of incidents occurring between ages 16 and 24.1,2 Self-harm can be done with or without the intent to die; however, regardless of intent, self-harm carries the risk of suicide. If left untreated, self-harming behaviour can become more extreme and carry on into adulthood.

Dialectical behaviour therapy (DBT) is a pioneering approach to treating self-harm.3 DBT addresses the underlying causes of adolescent self-harm, including diffi cult family interactions and diffi culties controlling emotions. Adolescent DBT, as developed by Alec Miller and colleagues, uses dialectic (testing thoughts and beliefs through discussion) and behavioural strategies in an intensive 16-week treatment program.4 DBT provides individual therapy, family skills training and phone consultation for the client, and team consultation for the therapist.

Philosophical perspective

The theory behind DBT is based on dialectical philosophy, which emphasizes the joining of opposites. DBT is considered dialectical because it blends seemingly opposing therapeutic styles. The DBT therapist takes a dialectical approach by strategically balancing such goals as:

  • Pushing clients to change versus accepting clients exactly as they are in the moment

  • Being warm and supportive versus being more irreverent (being matter-of-fact or deadpan when the client presents problem behaviours)

  • Challenging dysfunctional behaviour versus being validating, which includes focusing on the aspects of the clients’ feelings and intentions that make sense (e.g., the desire to fi nd relief from emotional pain)

DBT is also dialectical insofar as the therapist aims to help youth and family members replace extreme viewpoints, which can cause family conflictand emotional distress, with more balanced perspectives that take into account all family members’ views and feelings.

DBT is behavioural because it draws on the strategies of cognitive-behavioural therapy. Cognitive-behavioural strategies include helping youth and family members analyze the triggers and consequences of their problems and learn new ways to think about problems and their solutions.

Primary treatment targets

In DBT, there are four primary treatment targets, which are approached in a specifi c order:

  1. Life-threatening behaviours are targeted. These include suicidal thinking, suicidal threats, active selfharm, and triggers of self-harm. One trigger is invalidation, which can include critical comments from others, or other people discounting the youth’s perspectives and feelings.

  2. Behaviours that interfere with therapy are targeted; for example, missing therapy sessions and other factors that make it diffi cult for the adolescent or family member to get to treatment.

  3. Behaviours that interfere with the quality of life are targeted. For instance, clients are assisted in reducing behaviours that create depression, social isolation and poor communication among family members

  4. Clients’ behavioural skills are targeted. For this target, a therapist evaluates clients’ coping skills, and teaches new skills to aid progress in therapy

Secondary treatment targets

There are many treatment targets that do not fall easily within the primary treatment targets addressed in DBT. These secondary targets can be thought of as tensions within individuals, and between family members. These tensions can escalate as people take opposing sides, or fall into all-or-nothing thinking. These opposite perspectives create actual feelings of tension within the teenager and the family, and trigger some of the primary problems, including ‘acting out’ behaviour that is targeted in DBT.

Secondary treatment targets include family members’ behaviours such as:

  • Swinging between extreme strictness and extreme permissiveness

  • Labelling normal teen behaviours as unhealthy, while not responding adequately to unhealthy behaviours.

  • Wavering between encouraging adolescent dependence versus forcing independence

When addressing secondary targets, one goal of a DBT therapist is to help teenagers and family members become more dialectical in their thinking. That is, therapists help family members avoid opposite and defensive positions, by helping them to consider what is wellfounded in their own and in other family members’ perspectives. By doing this, a therapist can help family members to support and value each other, thereby reducing out-of-control emotions within the adolescent and within their family.

Treatment structure

Components of weekly treatment include the following:

  • Weekly individual therapy: The teens attend this session alone or accompanied by family. The purpose of individual therapy is to develop skills and motivation in both youth and parents.

  • Weekly family skills training: Teens and their family members meet in groups to learn a range of skills, including emotion regulation, mindfulness skills, interpersonal effectiveness, and distress tolerance. They also learn a dialectical approach to life, which involves learning to see the different sides of a problem with nonjudgemental awareness. This is referred to in DBT as “walking the middle path.”

  • Telephone contact:Teens and parents can access their individual therapists to request real-time, onthe-spot skills coaching.

  • Weekly consultation team meetings: Therapists obtain training and supervision to support successful treatment

Stages of treatment

DBT is delivered in four stages:

  1. Stage one lasts for 16 weeks and focuses on achieving control over self-harming behaviour

  2. Stage two focuses on reducing post-traumatic stress

  3. Stage three focuses on increasing self-respect

  4. Stage four focuses on increasing a client’s capacities to experience joy

About the Author

Lisa is a registered clinical psychologist in private practice. She is also completing a research fellowship, sponsored by the Canadian Institutes of Health Research, at the Centre for Addiction and Mental Health in Toronto, Ontario

  1. Favazza, A.R. & Conterio, K. (1989). Female habitual self-mutilators. Acta Psychiatrica Scandinavica, 79(3), 283-289.

  2. Centre for Suicide Prevention. (2001, January). SIEC Alert#43: A closer look at self-harm. Calgary, AB: Author

  3. Linehan, M. (1993). Cognitive-behavioural treatment of borderline personality disorder. New York: Guildford Press

  4. Miller, A.L., Glinski, J., Woodberry, K.A. et al. (2002). Family therapy and dialectical behaviour therapy with adolescents: Part I: Proposing a clinical synthesis. American Journal of Psychotherapy, 56(4), 568-58

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