with Erica Rozmid, PhD, Anaid Atasuntseva, PhD, Rebecca La Prade, PhD, and Micaela Thordarson, PhD

The COVID-19 pandemic has produced an atmosphere of uncertainty and anxiety that has exacerbated mental health challenges for many – this is true for adolescents as well, especially those who may be intolerant of uncertainty and emotional distress. The need for effective emotional regulation strategies and methods to promote psychological flexibility is undeniable. Four clinicians shared their inpatient and outpatient experiences providing dialectical behavior therapy (DBT) to adolescents in a symposium at the American Psychiatric Association Annual Meeting, held online in May 2021.

DBT: How it Works

A Clinical History of Dialectical Behavior Therapy

DBT is an evidence-based cognitive behavioral treatment originally developed in the 1970s for chronic suicidality and other hard-to-treat psychiatric disorders, and in particular, those individuals who did not respond to standard cognitive behavioral therapy (CBT).1,2 DBT balances acceptance and change strategies that increase motivation, distress tolerance skills, and work on mindfulness, psychological flexibility, and adaptive perspective taking.

The therapy has been used to treat a variety of disorders involving emotional dysregulation, including borderline personality disorder (BPD), substance use disorder (SUD), and depression in inpatient, outpatient, individual, and group settings. DBT can be especially effective at preventing clinician burnout by giving practitioners the tools they need to help individuals with vacillating emotional states, manipulative behavior, and frequent hostility.2

In the realm of behavioral therapy, the “Ninja mindset” is a form of growth mindset marked by acknowledging the wisdom of patience, the necessity of challenging one’s fears, choosing a path of justice for the self and others, delaying gratification and resisting impulses, tolerating emotional distress, and maintaining  equilibrium in life.

DBT Teletherapy: How to Manage Avoidance & Means Reduction

Erica Rozmid, PhD, an attending psychologist at UCLA’s Youth, Stress and Mood Program (YSAM), shared with the APA audience the rudiments involved in delivering DBT via telemedicine and telehealth platforms to facilitate a Ninja mindset. In her clinical experience, there is no significant difference in outcome between in-person and telehealth therapy but she notes that the shift from one platform to another does require some adjustments from the clinician’s point of view.

In Dr. Rozmid’s practice, adolescents seem to prefer online group therapy sessions to in-person ones but the shift to virtual sessions tended to reduce group cohesiveness. Private, interpersonal relationships between patients may be more difficult to prevent when using an online platform, she told the APA attendees, as adolescents, in their seemingly infinite grasp of technology, can message each other during sessions (unless the feature is turned off by the moderator). On the other hand, she said, the increase in distractions at home can become an opportunity for young patients to practice mindfulness (more on this below).

Avoidant Behaviors in Adolescents

Managing avoidant behaviors can look different in a virtual setting. There will be times when adolescent patients want to end the meeting, explained Dr. Rozmid, and the barrier to do so is significantly lower when there are no physical rooms to storm out of. It can also be difficult to tell whether patients are looking at the camera or not. She recommends that clinicians prepare themselves and their patients for these eventualities in advance, a practice that can ease tensions on both sides of the call and give adolescents an opportunity to practice reducing avoidant behaviors.

See also, the adolescent brain in the pandemic.

Suicidal Ideation, Harm and Means Reduction in Adolescents

Means reduction involves reducing the means adolescents have available to harm themselves. Teletherapy can offer an opportunity for clinicians to verify that patients have reduced access to potentially harmful items, which can, in turn, improve parent/caregiver and clinician peace of mind. Dr. Rozmid introduced a tool created by the YSAM clinic to assist parents in making decisions about how to limit lethal means. The pilot program is being tested at Columbia University and should be available to the public shortly.

Using Teletherapy to Engage Adolescents in Mindfulness

Neurotypical adolescents are known for their emotional dysregulation and impulsivity, and these strong emotions can be especially challenging when also suffering from depression, anxiety, and/or suicidality. Without the tools to deal with them, adolescents experiencing uncomfortable emotions, such as extreme boredom, can be at higher risk of suicidal ideation. While it can be challenging to engage this patient population in mindfulness, the right tools can lead to tremendous benefits.

Anaid Atasuntseva, PhD, a postdoctoral fellow in the department of psychiatry and behavioral sciences at Stanford School of Medicine, spoke about how to engage teens in mindfulness, which is a core component of DBT. Dr. Atasuntseva recommends that mindfulness exercises be short and fun.

In her practice, she commonly starts with an active, high-energy activity like following along with a TikTok dance. To help patients describe their emotions, she picks an emotionally expressive image and asks them to describe it. She also recommends that more traditional meditation exercises be shorter than 1 minute and only incorporate classic exercises, such as body scans and breathwork, when patients are comfortable.

Once taught, mindfulness can be especially beneficial to adolescents. Because of their neurodevelopment, adolescents think about their thoughts differently than adults do. They tend to think every thought is important or meaningful, so teaching them to let their thoughts pass through them without judgment is invaluable. Mindfulness practice can also help to improve social connectedness, reduce the frequency and strength of negative thought spirals, and increase tolerance to emotional distress.3

The Importance of Family Support When Treating Adolescent Mental Health

The final panelist in the session, Rebecca La Prade, PhD, a postdoctoral fellow at McLean Hospital and clinical fellow in psychology at the Harvard School of Medicine, addressed the importance of family therapy when treating adolescents. Getting families on board ensures teenagers that they have knowledgeable adults in their own homes who care about their wellbeing and can coach them through as they practice mindfulness and emotional regulation. Family therapy can also provide clinicians an opportunity to reduce maladaptive behaviors and harmful dynamics that may exacerbate the child’s emotional dysregulation.

However, cautioned Dr. La Prade, it is not helpful for anyone to feel criticized or invalidated, even due to lack of skill, so clinicians may have to walk a fine line between correcting maladaptive behavior and ensuring that all family members feel safe. For all of its challenges, family therapy can be an excellent tool in a clinician’s arsenal when working with adolescents.

DBT and Phone Coaching with Teenagers, Adolescents

Micaela Thordarson, PhD, a pediatric psychologist at the Children’s Hospital of Orange County (CHOC) in California, shared how her practice has used phone coaching in DBT to help adolescents with mental health disorders. She defined phone coaching as access to clinicians outside of scheduled appointments and being available between sessions to guide in the use of new skills and prevention of further crisis.

Dr. Thordarson emphasized that phone coaching should not replace emergency services, a crisis hotline, or therapy. In her experience, most calls or texts require 5 minutes or less of clinician time to address, and the overwhelming majority are received during school, after school, or in the evening. She recommends clinicians use a separate work phone or a google phone number if they do not wish to share their personal phone number with patients.

In her practice, parents, adolescents, and clinicians had positive experiences with phone coaching. They felt safer knowing that they always had someone to talk to and clinicians love how easy it is to reinforce skills and prevent crises instead of just managing their aftermath. There was no change in compensation for clinicians using phone coaching in Dr. Thordarson’s practice, although some clinicians in other practices were able to secure higher rates of reimbursement from insurance companies. Overall, the brief, in-the-moment intervention that phone coaching provides helps enhance experiential learning, state-dependent learning, adaptive support seeking, autonomy, and skills mastery.

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Last Updated: May 25, 2021