Dialectical behavior therapy for adolescents: theory, treatment adaptations, and empirical outcomes

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 outcomes 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 underpinnings, adaptations, and outcomes of DBT for adolescents. DBT has been adapted for adolescents with various psychiatric 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 underlying dysfunction in emotion regulation among the aforementioned disorders and problem behaviors. Thus, the theoretical underpinnings of DBT suggest that this treatment is likely to be beneficial for adolescents with a broad array of emotion regulation difficulties, particularly underregulation of emotion resulting in behavioral excess. Results from open and quasi-experimental adolescent studies are promising; however, RCTs are sorely needed.