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August 6, 2007

Dialectical Behavior Therapy for Adolescents With Bipolar Disorder

Here is a summary of an initial study on the benefits of Dialectical Behavior Therapy (DBT) used in the treatment of adolescents with Bipolar Disorder. This is a newer therapy with less than 20 years exposure to the mental health community that has been proven effective for other disorders. The results of the study, although preliminary, show that DBT may be an effective psychotherapy for bipolar disorder. We have also included numerous resources for further reading on DBT.

Who did the study?

Tina Goldstein PhD and colleagues from the Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center conducted this study. It was supported by the American Foundation for Suicide Prevention (AFSP), grants from University of Pittsburg and NIMH. It was released in the July issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

What did they study?

This article features a small study that looks at a therapeutic method not previously researched on adolescents with bipolar disorder. This therapy is called Dialectical Behavior Therapy (DBT), and is considered a “3rd wave” therapy, meaning it is of the newer generation in psychotherapy approaches (created in 1993). The study is very preliminary and does not include a control group -- therefore it has many limitations, and it’s hard to determine how this type of therapy measures up to other types, like cognitive behavioral therapy (CBT). But it is one of the first studies truly examining new and innovative therapeutic approaches on this growing population. Hopefully the results of the study, as well as its limitations, will only encourage more research into psychosocial treatments for people with bipolar disorder.

DBT was created by Marsha Linehan in 1993, and was the first therapy shown through control trails to be effective with Borderline Personality Disorder (BPD) clients, and it has been empirically validated with other populations. There are very significant similarities between BPD and bipolar disorder. Both exhibit mood swings, emotional dysregulation, chaotic relationships, instability, and behavioral disturbances to name just a few. These disorders are even similar enough that people are mistakenly diagnosed with one, when later it’s revealed they experience the other. There are some cases though, where people have co-occurring BPD and bipolar disorder. Because BPD can’t be diagnosed in teens, this study did not include any patients with known BPD.

DBT is a psychosocial cognitive-behavior therapy (though differing in some ways from CBT). DBT focuses on the larger context of behaviors, similar to a systems approach. This means that behaviors are understood in the context they occur; as in when, with whom, and where they occur. DBT also focuses on skill building in 4 areas, mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation. DBT utilizes “homework” and monitoring similar to CBT – clients are asked to keep a diary. Clients record in the diary their moods, stability of their mood, their behaviors, and application of skills learned in DBT. Traditionally DBT incorporates both individual and group therapy.

But one main difference of DBT – that is not usually a part of CBT -- is its integration of Buddhist and Zen philosophies, which are common in other “3rd wave” therapy approaches. DBT encourages clients to be mindful of the current moment. This concept of mindfulness is the intentional awareness of thoughts, feelings, experiences, and reactions. It also encourages clients to accept reality without judgment. Being mindful is highly beneficial because it allows people to take a step back and react with full intent. This means that a person can work to avoid reacting “irrationally”, over emotionally, or out of rage. This would be of great benefit for any adolescent, since impulse control can be difficult during that developmental period.

Why did they do it?

Bipolar Disorder in children and adolescents is an increasing issue. More children are being diagnosed earlier, and the course of the disorder is different than it is in adults. It currently affects about 1% of adolescents. Bipolar disorder is a particularly important issue when working with adolescents because its onset is associated with suicide, substance abuse, unprotected sex, and other risky behaviors. Bipolar disorder takes this already difficult developmental period, the teenage years, and makes it even more complex and hard to navigate through. Adolescents with bipolar disorder have a higher rate of psychosis, co morbidity, and hospitalization. Early intervention is very crucial; otherwise these teens with bipolar disorder can experience a “deteriorating course into adulthood, with poor outcomes including chronic functional impairment and treatment resistance.”

“To date, there are no empirically validated – supported by a wealth of research - psychosocial treatments for bipolar disorder adolescents.”

But there is some support for certain therapies, and promising results from initial trails. CBT, family-focused therapy, and psychoeducation have shown the most promise.

These researchers choose to look at DBT, and whether it can be beneficial for adolescents with bipolar disorder because of its emphasis on issues that plague bipolar disorder . The similarity of BPD and bipolar disorder clued these researchers in to the possibility of DBT working effectively for these adolescents.

How did they do it?

Because working with adolescents is different than working with adults, and suicide is an increased risk for those suffering with bipolar disorder, the researchers implemented DBT adapted for suicidal adolescents (Miller et al 1996). This incorporated “age-appropriate language, decreasing treatment length, and involving family members in skills training groups.”

Tina Goldstein PhD, the author of the paper, administered all the therapy; she received education on the DBT model, as well as training and supervision before and during the study. In the therapeutic community, being competent in a discipline is usually defined as having education, training, and supervision – all of which were met here.

The structure of the therapy included skills training, which was with done with the family unit in hopes of teaching new skills, and individual therapy, which was to help the adolescent apply these new skills in their lives.

“During the acute treatment period (months 1-6) participants received 24 weekly 60-minute sessions, alternating between the two modalities: 12 family skills training and 12 individual therapy sessions. The continuation phase of treatment (months 7-12) consisted of 12 total sessions (six family skills training, six individual therapy) during which the aim was to consolidate gains and review skills application.”

Family Skills Training
Sessions 1-2: Psychoeducation on bipolar disorder and emotional vulnerability, and emotional dysregulation

Emotional Vulnerability (experienced by adolescents with bipolar disorder)
1) Sensitivity to emotions: Things bother you that may not bother other people. Your emotional reactions are easily triggered.
2) Intensity of emotions: When something bothers you, your emotional reaction is more intense or extreme than it might be for other people. You feel things very strongly.
3) Duration of emotions: When you have an emotional reaction, it lasts longer for you than it might for other people. Your emotions take longer to come back down to baseline.

Emotional Vulnerability + Difficulty Regulating Emotions = Emotional Dysregulation

*The 4 DBT modules*
Sessions 3-4: Mindfulness
Sessions 5-7: Distress Tolerance
Sessions 8-10: Emotional Regulation
Sessions 11-12: Interpersonal Effectiveness

Individual Therapy Sessions: Theses sessions were tailored to the individuals needs. Priority was given to issues such as suicide and medication nonadherence. Problems solving skills were taught, as well as behavioral management.

Skills Coaching by Telephone: Part of DBT is the openness and availability of the therapist. In this study the therapist was available by pager to provide telephone coaching as needed. The appropriateness of when to call was discussed, and over using this privileged - or under using it - was considered “therapy-interfering” behavior, and openly discussed in sessions.

Diary Cards: Participants completed diary cards daily, as part of their “homework” and progress. The diary cards assessed mood, sleep, suicidality, and medication adherence. The cards also asked which DBT skills were used, as well as logging individual goals of each client. Monitoring alone has been shown to be highly effective in changing behaviors – bringing awareness of behaviors to someone influences how they act - this diary technique not only monitors behaviors, but it also helps the client and therapist stay on the same page with regards to how the client did at home away from the therapy session.


Medication Management: Because bipolar disorder is marked by difficult mood swings that may prove dangerous or inhibit other treatment, all clients were on medication to stabilize their moods and reduce bipolar disorder symptoms. The DBT therapist collaborated with the psychiatrist and medication management sessions were given weekly to bi-weekly till stabilization. After stabilization, clients saw the psychiatrist as needed and for routine check-ins.

Who were the participants?

The study included 10 participants and at least 1 family member, though only 9 completed the study – one relocated to another state and was unable to continue. Because this is an open trail and a very long (1 year) study, as well as one that requires a lot of activity/commitment on the part of the adolescent and the family, the small sample is not surprising.

The participants were between 12 and 18 years old, with 16 being the average age – all with a diagnosis of Bipolar Disorder, I, II, or NOS (not otherwise specified). All participants had either a depressive, manic, or mixed (both manic and depressive) episode in the 3-months prior to the study. They were all on medications, and some even had co morbid diagnoses; such as, anxiety, substance abuse, and suicide attempts. All participants had at least 1 family member willing and able to participate in the study and skills training, and none of them were currently participating in any psychosocial therapy.

These participants, when compared to the norm of adolescents with bipolar disorder, were considered highly symptomatic and more severely affected by bipolar disorder. The authors speculated this may be because more severely affected patients and families were more motivated to participate. This shows that DBT had benefit to those with severe symptoms, and may be more successful for those with milder bipolar disorder.

What were the results?

Feasibility: Because only 1 client withdrew, and not for reasons due to the structure of DBT, and each participant attended 90% of the session, DBT for the treatment of adolescents with bipolar disorder seems feasible and easy to administer.

Satisfaction: The study measured how satisfied the patients were by administering post treatment satisfaction questionnaires. Both adolescents and family members reported that the frequency of visits and the length of treatment were acceptable. Satisfaction ratings showed that they were also highly satisfied with the DBT approach, as well as the progress the patients made during the 1-year treatment.

“In fact, following the 12-month program, many parents expressed a desire for continued DBT.”

Suicide and Self-injurious Behaviors: Although 80% of the participants were suicidal at the start of the study, as well as some had attempted suicide in the past, there were not suicide attempts reported during the study. There was no significant change in non-suicidal self-injurious behavior – such as “cutting”, but non of these acts were reported in the last assessment of the study. This may mean that an improvement in these behaviors will occur if treatment continues longer.

Emotional Dysregulation: They measured emotional dysreulgation (which is often the difficulty in regulating ones emotions, and displaying extreme emotional responses) with the Children’s Affective Liability Scale (CALS), which has been validated in other studies as an effective measuring tool. They found that initially, participants had scores similar to those of psychiatric inpatients. At the completion of the DBT treatment, the participants had scores below that of outpatient samples. This means that patients were better at regulating their emotions.

Mood Symptoms: The participants showed significant improvement in depressive symptoms. There were no differences reported on manic symptoms, but the authors note that manic ratings were fairly mild even before starting treatment.

Interpersonal Functioning: There were no significant improvements with interpersonal functioning reported.


Because this study has a small sample size, its not the most reliable study for all adolescents suffering from bipolar disorder. The study also lacks a control group, or a comparison to other therapeutic methods, such as CBT, psychoeducation, and family-focused therapy – all of which are promising treatments for this population.

The authors encourage future studies, with more participants, and controlled trails. They also plan to further examine post treatment DBT skill acquisition, meaning how much of the DBT skills did the clients learn, and therefore how much was the skill learned related to their improvement.

Take Home message:

DBT is a unique approach that combines emotional regulation learning, and mindfulness with behavioral approaches. It’s a possible new therapeutic method for treatment of adolescents with bipolar disorder. Because its intent is for a disorder marked by similar symptoms and deficits, it’s an appropriate method of treatment. DBT is empirically valid for other populations and further study may reveal its full potential for treating bipolar disorder. DBT is currently used in many treatment centers, even those dealing with substance abuse, psychotic disorders, and dual diagnosis. The results here are preliminary, but promising, and should encourage further research into DBT’s benefits on bipolar disorder.

Full Article:
Dialectical Behavior Therapy for Adolescents With Bipolar Disorder: A 1-Year Open Trial.

DBT Resources:

DBT Therapist Directory

DBT Self Help Website: Created by individuals who have gone through DBT, not by professionals.

Behavioral Tech, LLC: Marsha Linihans DBT resource site.

Some Books on DBT:
Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance (good for both clients and clinicians)
Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control
The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation

Some Centers Offering DBT Programs
Youth Care: a therapeutic boarding school and residential treatment center for youth
Le Salva Group for Mental Health, Palo Alto Ca.
Lakeview Center for Psychotherapy, Chicago: site offers basic FAQs about DBT.
DBT Center of Michigan
Walden House, San Francisco Based: Substance Abuse and Dual Diagnosis Program
San Francisco DBT Center: Offers everything DBT, therapy, resources, and training.


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