Skills training addresses skills deficits believed to be causing the suicidal adolescent’s problems. DBT systematically teaches 5 skill sets:
- emotional regulation
- mindfulness
- interpersonal effectiveness
- distress tolerance
- “walking the middle path. “8
These skills are designed to treat specific problems common among suicidal adolescents and their families. For example, suicidal adolescents often experience a spike in emotions that leads to urges for ineffective behavior, such as attempting suicide or attacking another person. Table 3 provides steps that teach “opposite action, “ which can reduce ineffective emotions and problematic urges associated with these emotions. Table 4 provides mindfulness practices that can help patients address problems such as mindlessness and avoiding the present moment. Although adolescent DBT skills training is similar to that in adults, Table 5 describes key differences.
Table 3
Teaching adolescents ‘opposite action’
| Ask, what emotion am I experiencing? (eg, anger) |
| Ask, is it effective for me to experience this emotion? Does this emotion fit the facts of the situation? (If the answer to either of these questions is no, then proceed) |
| Ask, what is the action urge associated with this emotion? (eg, to attack) |
| Do actions that are opposite to the action urge (eg, gently avoid the person with whom you are angry) |
| Act opposite to the action all the way and completely (eg, have empathy and understanding for the other person, change your body posture by unclenching hands and relaxing facial muscles) |
| Keep repeating the opposite action until the emotion decreases |
| Source: Reference 8 |
Table 4
Mindfulness practices: Teach adolescents to live in the present moment
| Practice | Description |
|---|---|
| Mindful eating | Provide patients with a piece of food such as a carrot slice, raisin, saltine, candy, etc. Instruct them to eat the food using all of their senses. Tell them to observe it visually, notice the smells and textures, the taste, etc. Encourage patients to notice all that goes into the process and mechanics of chewing and swallowing. Observe the taste, changes in texture, and even sounds |
| Observing different body parts | Ask patients to get in a comfortable, relaxed, and still position. Provide verbal instructions to attend to a body part. For example, ‘Focus your attention on your left knee. If you notice your mind wandering, bring your attention back to your left knee. ‘ Spend about 30 seconds attending to the body part and then switch to another body part (eg, upper lip, right ear lobe, third toe on your left foot, etc. ) |
| Mindful blowing bubbles | Provide patients with bubbles and ask them to blow bubbles. Pay attention to the activity and the bubbles themselves. If patients get distracted or have judgments about the activities, instruct them to notice these thoughts and bring themselves back to participating |
| Source: Reference 8 | |
Table 5
Adapting DBT skills training for adolescents
| Alteration | Reason |
|---|---|
| Added ‘walking the middle path’ skills | This skill set was added to elaborate on topics including validation, polarities in behavioral patterns in the family, and how to apply learning principles to the self and others. The goals of these skills are to decrease parent and teen conflict, increase understanding of typical vs pathological teen behavior, and effectively change behavior through contingency management |
| Parents and family members of the suicidal adolescent attend weekly skills training | Generalization of the skills outside of therapy is more likely to occur with families’ help. Additionally, having family members practice the skills will decrease the likelihood that the home environment invalidates the adolescent, reinforces problematic behaviors, and/or persists in familial dysfunction |
| Duration of skills training decreased to 16 weeks | Increases the likelihood that adolescents complete therapy by reducing the number of skills taught |
| Some handouts have been modified | The forms are more appropriate for adolescents and family members |
| Source: Reference 8 | |
Telephone consultation. The purpose of brief (5 to 15 minutes) telephone consultations between a patient and therapist is to:
- enhance the likelihood of effective behavior
- coach the use of skills
- decrease the likelihood of problematic behaviors.
DBT telephone consultation for adults differs from that for suicidal adolescents. In DBT for adults, if a patient engages in NSSI or suicidal behavior, there is no telephone contact for 24 hours. This rule aims to avoid reinforcing the behavior with additional contact. However, this rule does not apply to adolescents because restricting adolescents’ access to resources for managing the aftereffects of self-harm could increase their risk of injury or death. Nonetheless, adolescents are strongly encouraged to use telephone coaching before rather than after self-harm. A second difference is that in DBT for adolescents, telephone coaching is offered to parents to help them use skills in the home. To avoid complications with dual relationships, the parents’ telephone coach should not be the adolescent’s individual therapist.