When Emotions Escalate: DBT for Adolescents and Families

DBT’s Biosocial Theory provides a framework to understand the etiology and maintenance of emotional dysregulation. The theory proposes that the adolescent has a biological vulnerability (i.e., sensitivity, reactivity, and a slow return to emotional baseline) that transacts over time with an environment experienced as invalidating. This environment can include parents, siblings, peers, teachers, social media, and community. An invalidating environment dismisses, rejects, trivializes, ignores, or punishes communication of emotional experiences. As the environment continually tries to settle down the sensitive teen’s emotions, it has the reverse effect and in fact exacerbates the teens‘ emotional arousal. As the arousal increases, the environment tries harder to reduce emotion expression to no avail. 

First, as mentioned above, we teach family members, teens, and school personnel, the Biosocial Theory of Emotion Dysregulation, and teach them how to increase validation and better regulate their emotions. DBT believes many adolescents’ emotional and behavioral problems are due to skills deficits, not merely a lack of motivation or caring. Thus, DBT providers teach skills in skills training groups, and strengthen these skills in individual therapy and family sessions. Coaching is another available treatment modality, in which teens or parents can reach out for real-time skills support to manage escalating conflicts or distress before acting on emotion-driven urges that can make the situation worse.

As described in Biosocial Theory, the transaction between emotional vulnerability and an invalidating environment maintains the cycles of emotional outbursts and conflict escalation.  With highly sensitive teens, emotional expression tends to be invalidated or punished.  As the teen’s emotions escalate further, the environment tries to reduce them further, and at times, may intermittently reinforce them by giving the adolescent the desired understanding or behavioral response. This leads to a cycle of chronic dysregulation where the teen oscillates between suppressing their emotions or escalating their emotional expression. This theory informs the treatment insofar as 1) to explain this biosocial theory transaction to teens and caregivers and 2) reduce invalidation and increase validation among family members, and 3) it also teaches emotion regulation, so that teens and caregivers learn strategies to better regulate their own emotions. 

All of the DBT skills are relevant for helping adolescents reduce their emotional intensity and pause before acting. Core Mindfulness skills are most critical to increasing awareness of what they are feeling in the moment and helping them make wise mind choices about how to manage their emotions and behaviors.  Distress Tolerance skills help teens ride out their impulse urges without making the situation worse. Emotion Regulation skills teach teens to identify and label emotions, reduce emotional vulnerability, and change unwanted and intense emotions once they have occurred. Walking the Middle Path skills help teens think more flexibly and learn how to better validate others and themselves. Finally, Interpersonal Effectiveness skills teach adolescents and families to ask for what they want skillfully, while validating the other and speaking gently and at the same time maintaining their self-respect. Taken together, these skills help adolescents respond more thoughtfully and effectively when emotions begin to escalate.

Many parents first need a chance to be heard, validated, and supported, as they often have experienced shame in prior treatment interactions. Parents participate in skills training alongside their adolescents in order for them to acquire and strengthen the same DBT skills that their teens are learning. Once skills have been learned, we recommend family sessions to put them into practice and directly target maladaptive transactions and reinforce effective skill use. When parents have more significant skills deficits, we often recommend separate parent sessions to provide extra support to help parents respond effectively during high conflict moments. 

Dialectics teach all of us, including clinicians, the notion of multiple truths and the need to search for what is being left out of a given perspective. When working with families, therapists take the stance for searching what is valid on all sides rather than getting pulled into a polarized stance. We recommend using a both-and approach rather than an either-or approach and making this explicit to families and modeling this way of thinking to help navigate conflicts. It is also important that the therapist remain mindful when engaging with dysregulated families: fully present, observing and describing non-judgmentally their own reactions as well as those of others in the room. The therapist strives to help family members move beyond polarized positions and work towards Middle Path solutions.