CPTR: How did you become involved with dialectical behavior therapy (DBT)?

Dr. Miller: In the mid-1990s, psychologist Jill Rathus and I developed a treatment that adapted DBT for a suicidal adolescent population for whom there was no other efficacious treatment (Rathus J et al, Am J Psychother 2015;69(2):163-178). Many of these kids had depression and some had substance abuse problems, anxiety disorders, disordered eating, school problems, and family problems, in addition to suicidal behavior. So, this was a multi-diagnosis, multi-problem youth population that was very difficult to treat. We were at a loss for an effective treatment, and we came across this treatment called DBT. When we looked into it, it seemed to fit our population perfectly, even though it was developed for a different group at a developmentally different stage of life. We later coauthored three books on this treatment with youth:

1. Miller AL et al. Dialectical Behavior Therapy with Suicidal Adolescents. New York: The Guilford Press; 2007
2. Rathus JH and Miller AL. DBT Skills Manual for Adolescents. New York: The Guilford Press; 2015
3. Mazza JJ et al. DBT Skills Training in Schools: The Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A). New York: The Guilford Press; 2016

CPTR: What made DBT such a good fit for adolescents?

Dr. Miller: It all boils down to five main challenges that teens we worked with were facing, which were also common issues in adult women diagnosed with BPD. Firstly, these teenagers had a hard time managing their emotions, which could sometimes throw off other aspects of their life. Secondly, they struggled with building and maintaining relationships, whether it was with their family or classmates. The third challenge was their impulsive behavior, which often led to harmful actions like self-harm and other behaviors(eg, substance use, disordered eating). Next, they tended to think in absolutes when they were emotionally worked up. Their thinking could become quite extreme and sometimes even mildly paranoid. And finally, their self-identity was affected. The emotional instability made it tough for them to understand who they really were and what their goals or values were.

We found these challenges matched the ones identified by Linehan in her work with suicidal women diagnosed with (borderline personality disorder) BPD. This made us realize that DBT could also be beneficial for our teenage patients who were struggling with suicidal impulses and showed signs of BPD.

CPTR: How is treatment administered?

Dr. Miller: While traditional talk therapy can help, we found that teaching children practical skills is more effective for them. We aim to equip them with new ways of dealing with the issues we discussed earlier. For example, if they're struggling with understanding who they are, we guide them through mindfulness activities. If they're having a hard time controlling their emotions, we offer them various techniques to manage these feelings. To help with their relationship troubles, we teach them how to interact more effectively with others. For impulsive behavior, we provide strategies to tolerate and deal with stress better. And finally, to address their extreme thinking, we introduce a strategy called "walking the middle path," which helps them see things and act in a more balanced way.

CPTR: How exactly do you accomplish these goals in DBT?

Dr. Miller: Our approach is a multimodal treatment with five principal modalities (Miller AL et al, 2007). Number one is a skills class. We work with the teenager and one or both parents along with three or four families—so we have 12 or 15 people in a group. We teach in a two-hour format over 24 weeks. We don't run this like a regular therapy session. Instead, we teach practical techniques, review homework, and role-play how to use these new skills in a group setting. Modality number two entails individual therapy sessions each week. During these sessions, we review a diary card where the patients record their emotions, urges, and the skills they've used. We then figure out a plan to decrease harmful behaviors and increase helpful ones. We also analyze the function of their behaviors and suggest alternatives. We use a lot of validation to ensure they feel understood as they navigate these changes.

CPTR: What’s the third modality? 

Dr. Miller: The third modality is telephone consultation that happens between sessions, because we feel like many of the kids and adults we work with need coaching. It is one thing to go to a skills group on a Wednesday night; it is another thing to put those skills into action on Saturday night. What does the young person do when they are overwhelmed by emotion and they can’t remember what skills they learned a week or two earlier? They will call their therapist for coaching before they engage in the problem behavior. Similarly, the parent attending skills group is encouraged to call the skills group leader for skills coaching related to how to manage a challenging situation with the teenager.

CPTR: What comes next in your approach to DBT?

Dr. Miller: The fourth modality is specifically for therapists. We bring all the individual therapists and skills trainers into a therapist consultation meeting that has two functions. One is to ensure that we are applying DBT with fidelity—kind of a group supervision. The other is to provide support (aka “therapy”) for the therapists because there can be high rates of burnout working with a multi-problem, suicidal population and we want to make sure that we nip that in the bud before it gets to be problematic for the therapist, the patient, and the family. 

CPTR: And what’s the last element?

Dr. Miller: The last modality includes parenting and family therapy sessions as needed. We offer sessions to help navigate some of the challenges of the environment they are struggling with, help them communicate, and help them learn how to resolve conflicts more easily using DBT skills.

CPTR: Does the training involve family member skills training as well?

Dr. Miller: Yes, the family member, usually a parent or caregiver, will come with the youth to skills training groups one night a week. Then we will have additional family sessions as needed to help with specific issues pertaining to that family. 

CPTR: Earlier you mentioned a strategy that you developed for adolescents called "walking the middle path.” Can you elaborate on exactly what this means for patients?

Dr. Miller: Sure. "Walking the middle path" is made up of three main skill sets.

The first is validation skills which is truly a superpower if used correctly. Let's say a teenager is having a meltdown because they got a poor grade. It's easy for a parent to say, "It's just one grade. You'll do better next time." But that might not help the teen feel understood. So, we teach family members and the teens how to validate each other's feelings. They would say something like, "I can see how upset you are about this grade. It feels like a big deal to you." This kind of communication can help de-escalate emotional reactions.

Secondly, we teach families about behavioral principles of learning. Imagine a teen has started doing their homework regularly, a behavior parents want to encourage. We teach the parents how to reinforce this behavior, like giving positive feedback or rewards. We also guide them on when to ignore unwanted behaviors, like sulking, and how to effectively administer consequences if necessary.

Lastly, we promote dialectical thinking and acting. This is about understanding that multiple truths can coexist. Let's take a common scenario: a teenager wants to stay out late with friends, but the parent thinks it's too dangerous. Here, both have valid points. The teenager wants to socialize, but the parent is worried about safety. Instead of sticking to their viewpoints, we encourage them to find a compromise or a "middle path." For instance, they might agree that the teen can stay out late, but they should check-in periodically. This approach helps to navigate conflicts and improve family relationships.

CPTR: I understand that you are applying some of these DBT techniques in classroom settings. How does that work?

Dr. Miller: We've found that DBT can also be very effective in schools. We teach life skills not just to at-risk students but to everyone. We have general teachers, for instance, guide students in mindfulness, helping them focus and manage distractions better. We believe that if we can teach subjects like English and Math, we can also teach students these crucial life skills.

For those who need extra help, we offer a more intensive DBT program. This includes weekly individual counseling, group skills training, on-call coaching during school hours, and a DBT provider consultation team. We've implemented this approach in many schools across the US and even internationally. (Miller et al, Psychol Sch 2023;60(8)2762-2781; Mazza JJ et al. Skills Training for Emotional Problem Solving for Adolescents (STEPS-A): Implementing DBT Skills Training in Schools. New York: Guilford Press; 2016).

CPTR: Can you share what the research says about DBT with adolescents at risk for suicide? 

Dr. Miller: With two significant studies conducted by different research groups, DBT has become the foremost evidence-based treatment for suicidal teenagers.

The first study was done in Oslo, Norway (Mehlum et al, J Am Acad Child Adolesc Psychiatry 2014;53(10):1082-1091). In this trial, DBT proved to be better than enhanced standard care, including cognitive-behavioral therapy and psychodynamic therapy. The adolescents receiving DBT showed considerable improvements in their depression levels, symptoms related to borderline personality disorder, and instances of deliberate self-harm, which encompasses both suicide and non-suicidal self-injury, over 19 weeks.

The second study (McCauley E et al, JAMA Psychiatry 2018;75(8):777-785) also found DBT to be more effective than individual and group supportive psychotherapy. It led to a reduction in both suicidal and non-suicidal self-harm behaviors among the teenagers, as well as other positive outcomes. So, the evidence strongly supports the use of DBT in working with suicidal adolescents.

CPTR: What guidance do you have for a clinician coming up to speed in the skills and methods teaching of DBT?

Dr. Miller: Certainly, having a strong cognitive behavioral therapy (CBT) background helps. DBT is an extension of CBT, although with less emphasis on the cognitive piece. There is something about applying DBT that is different from most traditional psychotherapy. In DBT, the therapist is a teacher and a coach. When I was trained psychodynamically that wasn’t the model, so there are some interesting differences. I think a lot of people can do it; they just have to be willing to get comprehensive training and ongoing supervision in order to deliver the treatment with fidelity. The Linehan Board of Certification (DBT-LBC) is the leading certifying body for individual clinicians and programs. 

CPTR: There are lots of self-help workbooks on DBT skills. I wonder if you have thoughts or suggestions on how therapists and clients might make use of these resources?

Dr. Miller: There are some books that I think are useful and that are written by people who are well trained in DBT. For example, Shari Manning’s book Loving Someone with Borderline Personality Disorder: How to Keep Out-of-Control Emotions from Destroying Your Relationship (New York: Guilford Press; 2011), written for family members, is a fantastic resource. She is an expert in DBT, and it shines through in that book. Some of my clients have used some interesting smartphone apps where you can actually look up skills on your phone. Technology can augment psychotherapy.

CPTR: Thank you for your time, Dr. Miller.

For those interested in finding a DBT therapist, DBT-LBC offers an online directory of DBT-Linehan board certified therapists here: https://dbt-lbc.org/index.php?page=101163.  

References in order of appearance:

Rathus, J., Campbell, B., Miller, A., & Smith, H. (2015). Treatment Acceptability Study of Walking The Middle Path, a New DBT Skills Module for Adolescents and their Families. American journal of psychotherapy, 69(2), 163–178. https://doi.org/10.1176/appi.psychotherapy.2015.69.2.163

Miller AL et al. Dialectical Behavior Therapy with Suicidal Adolescents. New York: The Guilford Press; 2007

Rathus JH and Miller AL. DBT Skills Manual for Adolescents. New York: The Guilford Press; 2015

Mazza JJ et al. DBT Skills Training in Schools: The Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A). New York: The Guilford Press; 2016

Miller, A. L., Gerardi, N., Mazza, J. J., Dexter-Mazza, E., Graling, K., & Rathus, J. H. (2023). Delivering comprehensive school-based dialectical behavior therapy (CSB-DBT). Psychology in the Schools, 60(8). https://doi.org/10.1002/pits.22887

Mazza, J. J., Gerardi, N., Dexter-Mazza, E., Graling, K., & Rathus, J. H. (2016). Skills Training for Emotional Problem Solving for Adolescents (STEPS-A): Implementing DBT Skills Training in Schools. New York: Guilford Press.

Mehlum, L., Tørmoen, A. J., Ramberg, M., Haga, E., Diep, L. M., Laberg, S., Larsson, B. S., Stanley, B. H., Miller, A. L., Sund, A. M., & Grøholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming behavior: a randomized trial. Journal of the American Academy of Child and Adolescent Psychiatry, 53(10), 1082–1091. https://doi.org/10.1016/j.jaac.2014.07.003

McCauley, E., Berk, M. S., Asarnow, J. R., Adrian, M., Cohen, J., Korslund, K., Avina, C., Hughes, J., Harned, M., Gallop, R., & Linehan, M. M. (2018). Efficacy of Dialectical Behavior Therapy for Adolescents at High Risk for Suicide: A Randomized Clinical Trial. JAMA psychiatry, 75(8), 777–785. https://doi.org/10.1001/jamapsychiatry.2018.1109

Manning, S. (2011). Loving Someone with Borderline Personality Disorder: How to Keep Out-of-Control Emotions from Destroying Your Relationship. New York: Guilford Press.