Anne Walters, PhD (Host 1): Being a teenager today is difficult. Social media plays a role in this difficulty, but it's not the only reason. The emotional highs and lows can be a lot to manage, and parents may not always know when to step in and how much to get involved. And even when parents do get involved by helping to solve problems, it's also important that teens have tools in their own toolkit to draw upon to manage the ups and downs on their own.

Host 1: One set of tools involves strategies from a therapy modality called dialectical behavioral therapy, or DBT. Today, we will learn what DBT is, how it works and who it can help. And we're thrilled to have Dr. Kerri Kim, a clinical psychologist at Bradley Hospital and Program Manager of the Mindful Teen Program in the studio, an expert on dialectical behavior therapy.

Greg Fritz, MD (Host 2): Welcome, Dr. Kim.

Kerri Kim, PhD: Thank you for that introduction. It is really great to be here finally joining you both. And I'm excited to help people learn more about dialectical behavior therapy.

Host 1: We're happy to have you and we're excited to dive deep into this topic. CBT or cognitive behavioral therapy seems almost mainstream now, which is wonderful because it's recognized as a form of successful therapy and treatment for so many. But DBT is also extremely effective for adults and teens who are in need of intensive therapy.

This is Mindcast: Healthy Mind, Healthy Child, a podcast from the mental health experts at Bradley Hospital, leaders in mental healthcare for children. I'm Dr. Anne Walters, here with my colleague, Dr. Greg Fritz.

Host 2: So, let's get the basics down. What is DBT and how did it start?

Kerri Kim, PhD: Well, I think I'll answer this in a few ways because DBT can be complicated and I want to be able to do it justice. So, first, DBT, dialectical behavior therapy is a third wave behavioral therapy that I often describe to families as being a close cousin to CBT, cognitive behavioral therapy, since that's the treatment approach that they're more likely familiar with when they're walking into our offices.

So, in a nutshell, DBT is a multimodal, principle-driven treatment that emerged as an initial effort to apply standard behavior therapy with adults who were chronically suicidal. The sole emphasis on change and problem-solving often led to patients feeling invalidated and hopeless. As from their standpoint, they were doing really the best they could possibly given those current circumstances and painful internal distress they were carrying around. So in response to this, treatment developers really swung in kind of the opposite direction and landed on a focus of unconditional warmth, positive regard and acceptance. And unfortunately, this too left patients needing more as they couldn't possibly continue on as they were living. Change was needed to some extent.

The result was DBT, as we know it, an approach that really synthesizes the emphasis on change that's reflected in CBT, that is change in thoughts, feelings and behaviors, with an added and equal emphasis on mindfulness and acceptance. The concept of dialectics is pretty core as the name might imply to the treatment. And this is the philosophical idea that two seemingly opposite notions can coexist. Both have kernels of truth and that we can move towards a middle path, middle ground between the extremes. This is included because with intense emotions often comes extreme rigid thoughts. One aim of DBT is to increase a person's cognitive flexibility, even in instances of experiencing intense emotions. The primary dialectic that comes up repeatedly in DBT treatment is that between acceptance and change, we're constantly doing that dance in our treatment with our families. Finally, DBT is a hopeful and skills-based intervention, that is the overarching goal of DBT is for individuals to achieve a life worth living, and this is accomplished by teaching individuals effective skills for regulating their emotions.

Host 2: When did it start?

Kerri Kim, PhD: So, Dr. Marshall Lenehan initially started creating DBT back in the late 1980s.

Host 2: I see. So, it's been quite that long.

Kerri Kim, PhD: It's been around quite a while, quite a while for adults. It wasn't then until, I think, early 2000s really, that it was modified for adolescents.

Host 1: And can you tell us a little bit about those modifications?

Kerri Kim, PhD: Absolutely. This is kind of my bread and butter of work on a daily basis. So again, back in the 2000s, there really was no clear evidence-based intervention specifically for treating adolescent suicidality and self-injurious behavior, and there was a pressing clinical need, one that of course still exists today. That being said, experts in the area of DBT modified the treatment to better fit the needs of teens and their families by, one, shortening the overall duration from essentially a one-year treatment length to about six months; two, by adding a skills module to the group component to target issues that are pretty unique that might arise between adolescents and their caregivers; and then three, by requiring families to actually participate in the treatment right alongside their adolescent.

Host 2: So, family therapy is an involvement of the family, is integral to the success of DBT. Can you tell us about the four main components of DBT?

Kerri Kim, PhD: Yeah. You're absolutely right, Dr. Fritz. The family involvement in DBT treatment is essential. And so, they are woven into the four main components of DBT, the first of which is a skills group. The focus of skills group is on teaching individuals effective skills to use in order to tolerate distress, regulate their emotions, and to navigate their social world. Skills group is run pretty to a class where co-leaders provide instruction and opportunities for in-session practice as well as assign homework for completion prior to the next session. Typically, the groups are scheduled for about once a week, two hours at a time. And while DBT with adults requires that only the identified patient attend these skills groups, with adolescents, it's actually required that at least one caregiver-- of course, the more the merrier-- attend each group, again right alongside their teen. And this is really to recognize that interactions are transactional, that an individual's environment impacts their functioning just as much as they impact their environment, and to provide a family really shared knowledge and language for coping effectively together.

The second component of DBT is individual therapy, and that's supplemented as needed with family meetings. In Mindful Teen here at Bradley Hospital, our comprehensive DBT program for adolescents, family meetings are held at minimum once during each skill module that's presented in group, and oftentimes more than that. The focus of the individual work is really on increasing the adolescents' motivation and application of the learned skills to their own lives. Typically, sessions are once a week, although can be increased to about twice weekly briefly to address any spikes in acuity.

The third component of DBT and the one really quite unique to the treatment is phone coaching. So, this focus is on skills generalization, crisis prevention. And for this to occur, that means that a clinician on a DBT team is available to patients and their parents or caregivers 24 hours a day, seven days a week.

Finally, there's the fourth component, and again, I kind of conceive these pieces as really important parts of the bigger puzzle, and this is the one that I see as the true backbone of the treatment model, and that's the consultation team for the providers. The team meets weekly and the focus is on supporting providers in their work with individuals who are presenting with risky and often life-threatening behaviors. Consultation team serves as an important function in maintaining treatment adherence, but also in preventing burnout.

In Mindful Teen, again here at Bradley, these components are presented in a pretty structured way. First, we invite patients and their families for an intake appointment, which is followed by about three to five weeks of individual/family sessions that are geared towards orienting them towards DBT and assessing their readiness for the treatment. If at the end of this orientation phase, families are still committed to completing the program, we have them join the 18-week multi-family skills training group. Again, this is where each teen and at least one caregiver receives skills instruction along with up to five other families. Throughout their time in skills group, they continue on with the individual sessions, family meetings, and then they gain access to that 24/7 phone coaching. And then all of the meanwhile, our Mindful Teen teammates weekly for consultation to ensure we're providing the best care possible while also taking care of ourselves.

Host 2: So, what are some of the skills and strategies that make up DBT especially focusing on teens?

Kerri Kim, PhD: So, in the original adult version of DBT, there are four skill modules that are presented in that group setting. Two of these modules, core mindfulness and distress tolerance, are more acceptance-based; where the other two, emotion regulation and interpersonal effectiveness, are more change-based.

As you might have noticed, mindfulness is the only skill set that's labeled as "core." This is because the ability to be present in the moment rather than stuck in one's thoughts about the past or the future is pretty critical to knowing when an effective skill is needed and then choosing the most useful one for that moment. Distress tolerance is focused on crisis survival and reality acceptance, acting on what is versus what you might want there to be, that is using skills to get through a painful moment in which you may have little control and have urges to act in ways that might actually escalate or worsen the situation.

Now, while distress tolerance is more of a short-term focused skillset, the emotion regulation module introduces a number of skills to change an individual's emotions and behavior over time. Similarly, the interpersonal effectiveness module, as the name might imply, is focused on skills useful in navigating relationships, really both in the short and the long term.

And then finally, in regards to the adolescent modification that was added, there's a fifth module called walking the middle path. This module focuses on problem-solving and resolving conflict more specific to the family system, to the caregivers and their teens together and again, by balancing that acceptance and change within their system.

One thing that I do tell adolescents and families I work with is that DBT offers a lot of options. It's a vast menu of skills. There are a ton of acronyms that we are presenting to them on a regular basis. It's almost guaranteed, in my view, that we'll be able to find some skills that work for some people some of the time, and then we'll be able to come up with backup plans for skills that can fit in in those moments that the original set weren't helpful.

Host 1: Well, that brings up a question really that, as with any form of treatment, sometimes it's just not effective. And so, what are some barriers that you see that could hinder DBT in that regard?

Kerri Kim, PhD: I'd say there are two to three barriers that kind of quickly come to mind certainly relevant to DBT, but really across treatment modalities. The first would be an individual's readiness for and their commitment to the treatment, that target area we're trying to assess in those first few sessions with an individual and their family. If someone is feeling forced to participate in a DBT program yet isn't bought into some extent, odds are they're going to continue filtering the treatment through kind of that rejection lens. Now, that's not to say we turn folks away when they first show up to our offices and are pretty hopeless. Really, we work with them to kind of orient them again to the treatment and to increase their readiness and prepare them for that work that lies ahead.

The second barrier to treatment success, I think would be skills practice outside of sessions. Again, this is pretty applicable across treatment modalities in a child's mental health. It's one thing to learn the skills, to sit in the skills group and hear the information, but really we need to implement them in our lives, so that they can become second nature. This is why that phone coaching component of DBT is pretty critical to the model. It facilitates skills practice and generalization while offering the individual support to actually implement new behaviors, ones that I suspect they would have done on their own if they could have.

The third and final barrier that comes to mind, which I think is more relevant to DBT with adolescents, is the family's level of involvement. Parents' willingness to team with the treatment team and their adolescent to improve circumstances versus expecting their teens alone to kind of go into the treatment and make the necessary changes is critical. And this is why parents, caregivers are included in the skills group and are welcomed into individual sessions and family meetings right along the way, and why we also provide them with phone coaching on their own, separate from their team.

Host 1: So, what or who are you targeting with this form of treatment?

Kerri Kim, PhD: Initially, DBT was created for folks presenting with chronic suicidality and, later, individuals who went on to meet diagnostic criteria for borderline personality disorder. Research now really does support that DBT can be useful in treating a range of clinical issues including bipolar disorder, disruptive mood dysregulation disorder and post-traumatic stress. Overall though, I think the kind of common thread targeted with DBT, as I mentioned before, is emotion dysregulation and specifically a skills deficit in that area of emotion regulation.

Host 2: So at the heart of it all is not only the characteristics of the treatment, but access to treatment. And so much of that access relies on basically luck. Would you comment on patients' access and lack of treatment?

Kerri Kim, PhD: Sure. I'm sure we've all heard the phrase behavioral health crisis. It's used repeatedly since the onset of the COVID pandemic. The reality though is that the pandemic only aggravated an already existing crisis. For example, despite so many clinical research and policy efforts focused on reduction, the rate of suicide has actually increased over the past decade plus. Now, it's the second leading cause of death among 10 to 24-year-olds.

Organizations offering an intervention like DBT, one that is considered the gold standard for treating suicide and self-injury among adults and adolescents, are few and far between, especially when we're talking adolescents. In part, that's because DBT, which we've discussed, is multimodal and includes a 24/7 access to clinicians that doesn't fit really the traditional categories that are used by insurers. To provide this lifesaving treatment in a way that is actually sustainable for an organization and the clinicians really requires insurers to adhere to mental health parity and cover such evidence-based treatments, even if they're not the norm and the ones that have historically been there, but really the ones that are the best supported and known to treat what we're needing to target.

Another big barrier to patients' access to DBT is the shortage of mental health professionals. Globally, that's true, but also including specific to DBT, those who are intensively trained in the treatment and functioning within a comprehensive program, one that includes those four components that we discussed. In order to address that particular barrier, organizations need to commit to providing optimal care, and this means hiring new clinicians, working with those who are already within their systems, incentivizing them for their hard work and supporting them truly in preventing burnout, which is a real issue among all mental health clinicians and certainly that's not exclusive of DBT practitioners.

Host 2: Well, that's very interesting. Certainly, it's never been more important that teenagers have access to effective and evidence-based mental health care, that's for sure. And we want to thank you for doing so much to serve the teens right here in Rhode Island with your program, Mindful Teens. And thanks so much for being here with us.

If you listeners found this podcast helpful, please share it on your social channels and check out our entire podcast library at bradleyhospital.org/podcast. This is Mindcast: Healthy Mind, Healthy Child, a podcast from the experts on children's mental health at Bradley Hospital. I'm Dr. Greg Fritz with Dr. Anne Walters. Thanks very much for listening.