DBT Expert Interviews: From Trauma to Eating Disorders

Practical DBT tips on substance use, trauma, chronic pain, and other conditions.

DBT for Teens: Teaching Distress Tolerance, Emotional Regulation, and Interpersonal Effectiveness

By Dr. Kirby Reutter, Ph.D., DBTC, LMHC, MAC & Dr. Jean Eich.

This presentation is an excerpt from the online course DBT Expert Interviews: From Trauma to Eating Disorders“.

 

Transcript

Introduction

In this section, Dr. Jean Eich explores the following skill sets concerning the adolescent population: distress tolerance, emotion regulation, and interpersonal effectiveness.

When teaching distress tolerance, Jean recommends first helping adolescents stabilize their acute symptoms through concrete, practical crisis management skills before teaching more abstract DBT skills. She recommends a focus on physical self-care, mindfulness of emotions, and opposite action when teaching emotion regulation to adolescents.

When teaching interpersonal effectiveness to adolescents, Jean recommends a strong focus on boundary setting, boundaries with peers, social media, and emotions. In particular, the DEAR MAN skill can be used for assertiveness, the GIVE skill for maintaining relationships, and the FAST skill for self-respect.

Teaching Distress Tolerance and Radical Acceptance to Adolescents

Kirby: How do you start teaching skills like distress tolerance and emotion regulation to adolescents?

Jean: The distress tolerance skills can be a lovely place to start, particularly the first half of that module, which is about crisis management. The wise mind ACCEPTS skill is an example. It’s about distraction, self-soothe, improving the moment. The idea is to try skills that help you be able to make this moment a little bit better.

They’re very concrete, easy to understand and to apply at the moment. That is often a helpful place to start in terms of coping because it doesn’t require a lot of brainpower to know, “It helps me to take a break from my stressor. It helps me to distract.” The job is figuring out how are they going to do that, and those crisis survival skills can be a helpful place to start.

When you progress with somebody through DBT, your first goal is stability. Help them feel like they have skills to be able to manage their triggers or that they can handle their emotions when they escalate. They can’t do a whole lot unless they have a little bit more control over how intense their emotions get. Those crisis survival skills are a lovely foundation for helping them be able to do that.

As a therapist, you don’t want the clients to be stuck in avoidance. You don’t want that stability to simply be about distracting from whatever is stressing them out or triggering their intense emotions. That’s where the rest of the distress tolerance and some of the emotional regulation skills can be helpful.

Once you have a foundation where you feel your teenager client has an understanding of how to cope with their triggers and their intense emotions, then talking about things like radical acceptance can be huge. Radical acceptance is about accepting what is and then being mindful enough to refocus your time and attention.

I teach radical acceptance in a similar way to the serenity prayer: accept what you cannot change so that you can focus your time and energy on what you can. That is a game-changer for so many people and so important for teenagers.

Although they have an increasing amount of independence and responsibility, there’s also still a lot that they don’t have control over in their lives. They don’t have control over when school starts and ends, or the homework that they get, nor over their parents and the rules or regulations that may exist in their home. Although they have more independence and freedom, they still are subject to a lot of things that they don’t have control over.

Many of my teenage clients are distressed by things they have no control over. Radical acceptance is such a game-changer for them because they have to accept all of these uncomfortable things that they don’t like and that sometimes they think are unfair.

This way teenagers can free themselves from wasting their time and energy trying to change them because most of them can’t be changed. It’s about refocusing their time and attention on what they have control of.

Early in my experience in teaching DBT to teenagers, I had this one teenager where that was a life-changer for her. Her mom had a lot of her stuff going on. She had quite a few mental illnesses that were not being treated. The adolescent constantly felt invalidated by her mom.

A focus early for her in treatment was, “How do I get my mom to understand this? How can I get my mom off my back? How can I get her to leave me alone sometimes?” There was such a deep desire in her to have things from her mom that her mom couldn’t give her at that moment.

Radical acceptance for her was a big deal because it was, “I’ve done everything that I can think of to try to inspire those changes in my mom and it’s not going to happen. That desire doesn’t go away and it’s still painful.”

When you let go of trying to make something exist that you have no control over, you feel a bit freer. That was the case for her. She didn’t all of a sudden have a magical relationship with her mom where she felt close to her, but she felt more accepting of her mom and more patient in her mom’s presence.

They got in conflicts a little bit less. She could put all of that energy that she was putting into trying to change her mom into other things that brought her fulfillment, in other relationships that could give her a few more of those pieces that she wasn’t getting from her mom.

Once clients have this foundation of stability that they know how to cope with things, a nice second focus is working on radical acceptance.

Emotion Regulation and Adolescent

Kirby: How do you teach emotion regulation to teenage clients?

Jean: An initial focus on emotional regulation can be simple basic self-care. I like to work with my teenage clients around the basics like, “How are you sleeping and eating? Are you moving your body sometimes?” Then I look at, “What are the barriers to that?” and, “How can we chip away at that so that your self-care is more taken care of?” When you’re more physically taken care of, you’re more resistant to intense emotions as well.

Beyond that, in mid to later stages of treatment, the goal of emotional regulation is to help clients allow themselves to simply feel their emotions and not feel like their whole world needs to be taken over by that emotion. Here is where skills like mindfulness of emotions and opposite to emotion can become helpful.

Mindfulness of emotions is simply allowing your emotion to exist. You’re not pushing it away and you’re not overfocusing on it. You’re letting yourself feel.

Opposite to emotion says although you’re feeling the emotion, don’t let it determine your decisions. Don’t let it create actions for you. You can still have control over how you behave even though you’re allowing intense emotions.

Kirby: When I taught opposite action to adolescents who were oppositional defiant, I would explain, “Look, you are already good at doing the opposite. We need to apply that concept to your urges. You can do this with everything else in your life right now. Why don’t we apply this concept to your urges?”

Teaching Interpersonal Effectiveness

Kirby: How do you teach interpersonal effectiveness to adolescents?

Jean: One of the themes that I find throughout teaching our interpersonal effectiveness skills is setting boundaries. Boundaries with teenagers can be so important. As an adolescent, relationships are so much more important than they used to be. Most teenagers are very relationship-focused. They spend a lot of time thinking about and being with their friends.

Boundaries can be important in all aspects of relationships. As I teach the interpersonal effectiveness skills of DEAR MAN for assertiveness, GIVE for keeping your relationships healthy, and FAST for having self-respect in relationships, I talk about boundaries. Establish the boundaries in terms of what you share with somebody.

A common struggle that some of my teenage clients get in is, “I confided in somebody and then they told everybody everything and so, therefore, I can’t ever trust anybody again.” They don’t open up very much which means that they feel fairly isolated in their relationships.

We help them be able to find a boundary. “Of course, your reaction after being hurt like that is to withdraw and not share anything with anybody. How is that serving you?” We can help adolescents to find a middle path in terms of establishing boundaries of what they share with other people.

Boundaries in terms of social media can be helpful to talk about. “What are you comfortable posting or not posting? How are you comfortable being talked to or talking to others? What are the rules of the road for you in terms of social media?”

Emotional boundaries are difficult to explain to teenagers. Helping them recognize that you can be very close to and connected to your friends or your partner and yet feel differently than them. Recognize that they could not be okay and you could still be okay or, on the contrary, you could not be okay and they could still be okay. Having those emotional boundaries where you don’t have to take on the emotions of other people and you don’t have to caretake other people’s emotions.

I teach interpersonal effectiveness to adolescents with a real emphasis and constant conversation on boundaries.

Main Points

  • When teaching distress tolerance to adolescents, it’s helpful to first stabilize acute symptoms through concrete, practical crisis management skills, such as distraction, self-soothing, and improving the moment, before teaching more abstract skills, such as radical acceptance.
  • When teaching emotion regulation to adolescents, it’s helpful to focus on physical self-care, mindfulness of emotions, and opposite action. Physical self-care helps clients understand how eating, sleeping, exercise, and symptoms all affect mood states. Mindfulness of emotions helps clients learn to allow their emotions instead of trying to avoid or escape them. Opposite action helps clients learn healthier ways of acting on problematic urges.
  • When teaching interpersonal effectiveness to adolescents, it’s helpful to use the DEAR MAN skill for assertiveness, the GIVE skill for maintaining relationships, and the FAST skill for self-respect. Interpersonal effectiveness especially needs to focus on boundary setting: boundaries with peers, boundaries with social media, and boundaries with emotions.

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