do you want to start therapy but are worried about what your parents might think? are your parents making you try therapy but you don’t know what to expect? whether therapy is your idea or theirs, this episode breaks down why dialectical behavioral therapy (dbt) can help families navigate even the most challenging mental health issues (content warning for brief mentions of SH).
today’s guest is dr. jill rathus— a world-renowned authority on dbt. she co-developed dialectical behavior therapy for adolescents and families alongside dr. alec miller and dr. marsha linehan and is the co-author of several of the leading texts on this subject, including the widely used dbt skills manual for adolescents.
in this episode, dr. rathus shares her expertise on a number of teen mental health topics, including how to tell if a teen is dealing with mental health issues and what steps a family can take to help.
we talk about:
• what an initial dbt appointment can look like
• common concerns that teens + parents have about mental health
• qualifying “normal” teen behavior vs. a mental health issue
• why it often takes a crisis for teen mental health to be taken seriously
• signs that a teenager is reaching out for help with their mental health
• how to validate someone who’s struggling (+ common invalidating responses)
• strict vs. lenient parenting styles + how that impacts teen mental health
• starting family therapy + what that involves
• applying therapy to daily life in ways that actually work
• why dr. rathus is hopeful about teen mental health
mentioned:
• dbt skills manual for adolescents
• dbt skills manual for adolescents: second edition (preorder)
[00:00:00] Sadie: Why does it sometimes take a crisis for a teenager's mental health challenges to be taken seriously?
[00:00:07] Jill: Often it's, you know, the squeaky wheel gets the grease, so it's the kid who has escalated their cries for distress that finally gets taken seriously because families are busy, hectic, and strained a lot of the time.
[00:00:19] Parents may not recognize warning signs because they're not trained mental health experts, or the kids may really be hiding the warning signs. They just might not see it until it reaches a level which is already very escalated, where they finally recognize it, or they finally make a suicide attempt and they get rushed to the hospital, and then the parents see it.
[00:00:41] It hits them all at once.
[00:00:47] Sadie: Jill Rathus, welcome to She Persisted. I'm so excited to have you here today.
[00:00:51] Jill: Thank you, Sadie. I'm excited to be here.
[00:00:53] Sadie: Of course. You are a psychologist, a professor, and you co-developed DBT for Adolescents, something I know very familiarly. I've done those worksheets so, so, so many times at this point. Mm.
[00:01:06] And you've spent decades working with teens who are struggling with their mental health, and then also their families, which is a really important part of the equation for that demographic. My goal for our conversation today is make it easier for people to understand why sometimes a crisis is what kind of is that tipping point for mental health challenges to be taken seriously, and also how families can recognize and respond to mental health challenges before it necessarily gets to that point, trying to be more preventative with their approaches.
[00:01:38] I wanted to start by setting the scene a little bit and kind of get your expertise. When a teen who is struggling comes into your office and their parents sit down with you, what does that room feel like? What does that therapy session often look like for people who haven't been in that position before?
[00:01:58] Jill: First of all, I would say people are both super anxious and have a lot of hope. We have to remember as psychologists we're that doctor's appointment that they finally made, finally had the courage to make, finally got their teen to agree to, or sometimes the teen is asking for treatment and are finally coming in, but also there are so many mixed emotions.
[00:02:19] Again, hope, but so much fear, anxiety, shame, worry. So there's a big need to just validate what it must be like and as they're expressing what it's like. And then just structurally, we will start with usually the parent or parents and teen together for a few minutes, asking them what brought them in, general goals.
[00:02:40] Of course, there's been some phone conversation first. And then separate them, and I like to actually meet with the parents first, but I always ask the adolescent's permission to do that. So I spend time alone with the parent or parents really getting the lay of the land, the history, and their concerns.
[00:02:59] And as long as the adolescent gives me permission to do that, that works really well. Then when I see the adolescent next, we switch and I thank the adolescent for their patience in waiting, and then I say something to the teen, usually like, "Now I'm gonna get the real story." You know, wink, wink. And they appreciate that.
[00:03:19] But the reason I ask the parents first is so many adolescents will be guarded when they first come in, and they just won't tell me about so many things that have gone on, that have actually happened and concern their parents. So I wanna know where to poke around and ask questions. I have standard questions that I always ask, but of course I'll try to touch on some things the parents have let me know about.
[00:03:44] And often they don't bring it up, but when I mention something, they will then talk about it. So I want my time with the adolescent to be really useful and productive. The other thing it looks like is parents usually wanna go on. They could talk all day about what's been going on. The teens are mixed.
[00:04:02] Some of them are quite chatty. Some of them are pretty tight-lipped or angry that they're there. And I think One of the key things, I mean, this is so basic, but just to truly listen and validate because a lot of parents will come in and say, "My teen isn't gonna talk to you. They don't open up. They, they are just shut down."
[00:04:24] Yeah, like, "
[00:04:24] Sadie: Good luck, have fun."
[00:04:26] Jill: Yeah, exactly. "Don't know what's gonna..."
[00:04:27] Sadie: Yeah.
[00:04:27] Jill: And then an hour later, I walk out with the teen, and the parent is often shocked, "What, an hour? What did you do in there for so long?"
[00:04:34] Sadie: Yeah, yeah.
[00:04:35] Jill: I'll often say to the teen, "Your parents said you weren't gonna talk. What made you talk to me?"
[00:04:42] And they usually say a couple of things. They say, "You really seem to get it, and you also were different than other adults 'cause I thought you were just gonna tell me what's wrong with me and what I need to do to change it." Mm. "But you were different." Yeah. "'Cause that's what a lot of adults in my life have been telling me."
[00:05:00] Sadie: Yeah.
[00:05:01] Jill: And so then I bring them back together and we talk about, a little bit about the structure of DBT- Mm-hmm ... and then that we'll enter into this pre-treatment mode and make sure they understand kind of what they're signing up for. But I, my goal is to help them both leave with hope and some sense that they'll come back again.
[00:05:21] Yeah. And that they're willing to go on this journey with me or with our team. Yeah.
[00:05:26] Sadie: And what does that sound like to validate- This teen who's sitting in your office, who has maybe done the brave thing of asking for help and advocated and told their parents that they need the support, or maybe is there because they have to be, but is still physically there, which we know in DBT you don't have to do anything.
[00:05:45] There's always the choice to not show up and not be at the appointment, and if you really wanted to, you could choose not to be a willing participant. What does that sound like to validate a teen who's in that position of in that first appointment trying to accept help and doing that really brave, courageous thing of being vulnerable?
[00:06:07] Jill: Yeah. Well, one of the things I often say for reluctant teens is, "I know it's not your choice to be here, and I know there's a million other places you'd probably rather be right now." And just from the beginning, I talk about how this must be hard, and not just hard, but listen to what they have to say and then really reflect back to maybe some accurate, hopefully mind-reading about emotions they might be feeling: the overwhelm, the stress, the sadness, the fear, the shame.
[00:06:40] If it's not accurate, if I don't hit the mark, I allow them to correct me, and then I spend some time on that. And it's asking them not only about what they've been struggling with, but if they don't think they need to be there or they just don't wanna be there, I'll often ask them why do they think their parents are concerned.
[00:07:01] Hmm. And then they'll often start complaining about the conflicts or challenges or, "My parents are overreacting," or, "My parents are the problem." And then I'll spend time validating what that must feel like. And again, not throwing the parents under the bus, obviously, ever, but just saying, "It must be so hard when you, you feel like you're never seeing eye to eye, or you feel like they're overreacting to what you're going through, or you feel like they're underreacting, that they don't get, ever, what you're going through."
[00:07:31] Yeah. Or if they would just stop fighting or if they would just stop yelling or if they would just give you more freedom. And so it's taking your time really understanding, trying to get into their world a little bit and understanding what it must be like. And by the way, I extend the same listening and validation to parents because they often at this point are having trouble trusting mental health professionals, trusting that they'll actually get the help they need, or feeling like a mental health professional will blame them for all their adolescent's problems.
[00:08:06] Mm-hmm. So really taking that time in the beginning and not glossing over it to get to my 80 questions- ... I think is just so key. I'll often let the adolescent take the lead in the conversation, and in my mind I know what questions I have, but I can get to them in a roundabout way. And as long as I let the client take the lead and feel like they have some control in the room, and also really maintain the non-judgmental stance.
[00:08:35] I mean, that's baked into DBT, and it's so important that we don't convey a quick judgment with our reaction, our facial expression, but really understand that these are people who are struggling and are finally vulnerable enough to come for help. Yeah. And so making them feel right away, like I'm on their side, I'm on their team, we can do this working together, are all things I try to convey
[00:09:02] Sadie: And having worked with so many families and so many teens, what do you often hear teens saying when you ask them, "Well, why do you think you are here?"
[00:09:11] And then how does that differ from what parents are saying and why they think their teen is in therapy? I imagine there's a disconnect between, like, "They're not going to school, and I'm exhausted. I just can't imagine doing one more thing," or, "They just won't study for the test, and I know I'm not gonna do well, so I won't even try."
[00:09:30] What are these common things that you hear teens saying when they come to that first session, and then similarly, parents?
[00:09:38] Jill: Yeah. Well, either they're saying, "It's not that big a deal," or, "I can do this on my own. I don't need all this therapy." In which case, we wanna ask, "Well, have you tried to do it on your own before, and how has it gone, and have you been able to, and how long have you been struggling with this, and how much does it hurt, and do you wanna change that pain?"
[00:09:59] And then often they will talk about all the pain they're in and all the struggles they've had. And yeah, I think you, you put it really well. They'll often talk about it from their perspective of, "People tell me I should just do this," and, "If I just studied harder," "If I just set my alarm earlier," "If I just went to bed on time," "If I just stayed off social media," you know, "I'd be fine."
[00:10:22] And they often say, "Well, none of those things are easy for me. It seems to be easy for other people. But first of all, social media is my lifeline, and my parents don't understand that. And second of all, I can't get up in the morning, and I can't get to sleep at night, and I can't focus, and I'm in class and I zone out, and I hate school, and the kids are mean.
[00:10:44] And it's not about trying harder. I'm trying hard every minute of every day, and nobody gets that. Nobody gets what a battle it is just getting through every day." And then the parents, exactly as you said, parents are often different 'cause they will sometimes say they just need to do this, that, and the other, and they mean so well and they are rooting for their kids.
[00:11:08] They don't understand often that their child is wired differently, is more sensitive, reactive, powerful emotions, or maybe is neurodivergent in some way, or because they're so depressed and have so many other issues such as anxiety or other problems, social problems, that they can't focus, they can't study, they can't do any of those things.
[00:11:32] If they could, they surely would because their lives don't feel good. So with parents, there is often a very well-intended sense of I wish they could just apply themselves more, and by the way, they better apply themselves to this therapy that we're investing so much time and energy in. So partly it is a lot of psychoeducation for the parents.
[00:11:56] The biosocial theory in DBT talks about how kids might have really powerful emotions and overwhelming obstacles that they feel, and then because it's harder for them, the environment they face is invalidating. And when parents say, "Just do better, just try harder," in a loving, even well-meaning way, it shuts the kids down more.
[00:12:19] So we talk about even right from the beginning that we may need a different approach with this child. Maybe your approach worked with your two other children, but it's not working with this child, so we need to figure out how to be better attuned and how to be effective in how we're gonna motivate your adolescent and even motivate them to do this therapy and give this all a try and make them feel understood.
[00:12:44] And then that will open them up for changing and trying harder and doing better, which of course is the ultimate goal.
[00:12:51] Sadie: Yeah.
[00:12:51] Jill: But it's not easy, and people in the adolescent's life, again, often with very well-meaning intentions, even teachers, coaches, even friends, oversimplify things for kids, the ones who are really struggling.
[00:13:07] Sadie: Yeah. One thing you're kind of alluding to here and that I imagine is really central in this initial conversation is the normalizing pathological behavior and pathologizing normal behavior. What is just being a teen and what is potentially a mental health challenge? And I think more than ever today, there's a lot of dialogue around, like, well, everyone is having mental health challenges, and I imagine for teens it's hard to be like, "Well, all my friends have mentioned these things," or, "I see online that everyone is going through this."
[00:13:40] And like you mentioned, sometimes there's real struggle and real pain, and you've tried by yourself, and you could benefit from support. And I imagine that's something that parents struggle with as well. I know in my own mental health experiences, there was a lot of things that were normal teenage life experiences.
[00:14:00] Like, my friendships really changed. I was a lot more irritable with my parents. My, like, hobbies and interests really evolved. Like, all those things happen to most kids as they go through teenage life, but for me specifically in that context, it wasn't just the surface level things change and evolve during those years, but more, like, self-isolating because I was struggling, and not just having different interests, but not enjoying things that I did before.
[00:14:27] And yes, there was irritability and conflict, but that was part of being depressed, not just normal back-and-forth pushing boundaries. And so I'm curious for you, how can parents tell the difference between normal teenage changes and signs of deeper mental health struggles? 'Cause I imagine that's something that is really, really hard to navigate.
[00:14:49] Jill: It is. It certainly is. And your parents, first of all, there's in the first place recognizing, "Is what I'm seeing normative?" teen behavior or is it problem behavior that I should be concerned about? And then their barometer really gets distorted after they discover that their teen has been self-harming or suicidal or has been hospitalized, because then all the normative teenage behavior that the teen may be working hard to get back to can be threatening to parents and scary and look like problem behavior.
[00:15:23] For example, wanting privacy in my room, or just being on my phone, or just wanting to spend time with friends, or being a little moody, and again, that increased need for privacy, that's normal. Well, they wanna be alone in their room. Does that mean they're cutting themselves? They wanna go out with friends.
[00:15:41] Does that mean they're getting high and drinking? A- and so that is very difficult for parents at all stages, before problems emerge, during, and after. So one of the things we tried to do in our manual, and by the way, we have a new edition of the skills manual coming out in a few weeks, the second edition, and we have updated and revised our handout on what's normative for adolescents and what's cause for concern or intervention.
[00:16:09] And what we tried to do is collapse all of adolescent development into one handout.
[00:16:15] Sadie: Let me see.
[00:16:16] Jill: It's
[00:16:16] Sadie: so great.
[00:16:17] Jill: So we do have one handout, and that was intended as a guide for kids even, but also parents to say, "I found out they had alcohol on their breath. Should I take them to the ER, or is this normative?"
[00:16:29] And a lot of parents, of course, they have good instincts, and they were adolescents too, but with their particular adolescent, they may not be sure. So we did write that handout, and we've updated it for screen time, social media. So one way to do it is we refer families to that handout, and it goes through everything from eating habits, to messy room, to self-consciousness, to moodiness, to increased conflict, to privacy, time with peers, peer influence, experimentation with different things that might be risky.
[00:17:05] And then we really hope that Therapists will understand and be able to help parents discern that because what we wanna look for that helps discern normative adolescent development from seriously problem behaviors are things like how long they're lasting. Is this just a tough night or a tough weekend, or has this been weeks and months on end?
[00:17:30] And is it impairing functioning? So has the adolescent stopped with their grooming? Has the adolescent stopped eating? Has the adolescent stopped going out and seeing friends? Has the adolescent stopped going to school or their grades are really dropping strongly? So we look for indicators that they're lasting and that they're affecting functioning, and that's a really good indicator.
[00:17:53] So it's not just severity. One adolescent might be emotionally intense and have some screaming fights with their parents, but they see friends, and they're loving at other times, and they are the star of the school play, and they're on the soccer team, and they go to school, and they're getting As and Bs, and a few screaming fights doesn't mean we need to get help necessarily, right?
[00:18:15] Sadie: Mm-hmm.
[00:18:15] Jill: So it's looking at the whole picture of functioning.
[00:18:18] Sadie: Yeah. And best case scenario, parents really have that in mind. They're like, "What's the duration? What's the impairment? What's the big picture here?" While also being aware of these, like, potential warning signs or things that are maybe not as normal of experiences and might suggest that there are mental health challenges.
[00:18:39] But oftentimes, teens still struggle, or they're not as open about what they're going through. It's harder to tell that there's a mental health challenge going on. Why does it sometimes take a crisis for a teenager's mental health challenges to be taken seriously?
[00:18:57] Jill: That's a great question, and I think parents may not recognize warning signs because they're not trained mental health experts.
[00:19:07] Most parents are not. So they might not see warning signs where the kids may really be hiding the warning signs. They don't really realize how they're struggling in school, or struggling with friends, or struggling with their emotions, or struggling with self-harm and suicidal thoughts and other problems because they're good at hiding it.
[00:19:26] And so first of all, they just might not see it until it reaches a level which is already very escalated, where they finally recognize it, or they finally make a suicide attempt, you know, and they get rushed to the hospital, and then the parents see it. It hits them all at once. I, I see a lot of parents who are...
[00:19:47] They come in shocked. They feel blindsided because their kids were concealing the struggles that led up, you know. And then they'll find knives in their room, or razors, or the kid will get off-guard for a moment and bare their arms to the parents, and the parent sees cuts going down their arm that they hadn't seen before, and things like that will happen.
[00:20:08] And sometimes it's because parents really do think it's normative adolescence, and they just think they'll get over it. It's a phase. It's no big deal. They'll grow out of it Or if I just keep telling them try harder, or I get them a tutor, or I spend a little more time with them, they'll be fine. Yeah. And they just, they don't realize the scope often.
[00:20:31] And one of the things we really try to do in therapy related to this is we try to teach parents to be not hypervigilant, but aware, alert to signs of distress and asking for help, and expressing painful, distressing emotions and problems at lower levels, rather than waiting till the five-alarm fire to respond and take them seriously.
[00:20:58] Because the other thing is that parents are busy, right? I mean, today's parents are busier than ever. We have economic stress and job stress. Parents trying to make a buck, keep a roof over the head, pay their rent. They might have multiple jobs, multiple children. They might be single-parent families. They have their own strains and struggles and stress.
[00:21:19] Even if they're two-parent families, we see marital conflict. Even if there's not marital conflict, people are just busy and absorbed in everything they have to do to get by.
[00:21:29] Sadie: Yeah.
[00:21:30] Jill: And so that's another thing. Often it's, you know, the squeaky wheel gets the grease, so it's the kid who has escalated their cries for distress that finally gets taken seriously because families are busy, hectic, and strained a lot of the time.
[00:21:45] Or they think it's no big deal, they'll be fine on their own. So we want to teach them that in order so that the kid doesn't have to feel like they need to express suicidal thinking to get you to put down your screen and stop, or put down the dinner that you're cooking and actually listen to them for a few minutes and try to talk to them and see what they want and need, and attend to them, which isn't easy for busy parents.
[00:22:10] I'm not saying it's easy, but they need to do it before it escalates. And often by attending and validating and listening and assisting a distressed teen, they will help them move forward without having to escalate to get that response, that needed response. And when I say having to escalate, I'm certainly not saying they do it on purpose.
[00:22:33] It's just learned over time, I, I need to keep intensifying my communication to get understood and taken seriously.
[00:22:42] Sadie: Yeah. And what do those lower level things sound like? Whether it was asking for help or the warning signs, the, like, smaller examples of vulnerability, what would that look like from a teen?
[00:22:56] Jill: Yeah. It might look like- "Can I talk to you? I had a really hard day at school. I feel like my friends don't wanna be my friends anymore," or, "I just saw on social media that they're all together and they told me they were too busy to go out and I'm just feeling really down," or, "I don't wanna eat dinner tonight 'cause I'm feeling fat."
[00:23:18] It could be anything. It could be, "I'm sad, I'm stressed, my school is overwhelming, I hate my teacher, I can't do the work, school is boring, I don't feel connected, people are mean to me at school, my partner broke up with me, my partner's being mean to me who I'm dating. I'm not sure I'm straight. I wanna talk to you about that."
[00:23:39] It could be just anything where busy parents who might be just dealing with so many things might say, "Okay, later," or, "Okay, soon," or, "Th- you'll be fine," or, "This is a phase." It could be anything like that.
[00:23:55] Sadie: And what reactions make people less likely to ask for help, especially in the future if they try getting that support, what reactions make them less likely down the line to go to that person again?
[00:24:08] Jill: Yeah, it's when people kind of overtly or s- even subtly dismiss them. Like, "I know you're in pain, but get back in the game," or, "I know you don't wanna do it, but just try harder," or just, "I'm gonna take your phone for the weekend until you show me all your work is done." Which by the way, I'm not saying that's always a terrible idea even, but when people feel like their concerns are dismissed or oversimplified, or someone doesn't have patience for them, or they get annoyed when they're expressing emotions, that may discourage them from talking more or expressing more if they feel judged.
[00:24:50] Sadie: Yeah.
[00:24:50] Jill: And I just wanna say that part of what we do and what we have in our new manual too, is we're teaching accurate expression to the kids, because sometimes the kids might be feeling so intensely that the way they express their distress can actually overwhelm other people if it's either irritable, angry, high level, or criticizing others somehow in, in what they're doing in response to them.
[00:25:20] So we also wanna teach kids that when they are making those bids for attention or time or asking for help, asking to be noticed at a low level of distress before they get higher, to be clear about their primary emotions, "I'm sad, I'm hurt, I'm feeling really worried about this," so that they're not already at the level where they're yelling, "I'm really angry.
[00:25:43] What's wrong with you? You always do this." And then s- a door slams, and then the parent is often gonna say, "Ugh, they're impossible," rather than meeting them with empathy. So in order to help them get what they want from the environment, we wanna also teach kids the most effective ways to express themselves so that they're more likely to get what they're looking for.
[00:26:04] Sadie: Yeah. And once you get past this point of establishing that someone's struggling, you're aware that something is going on mental health-wise, you've also talked about the kind of dialectic that exists in parenting style, where some parents will be really lenient in their approach and some can be really-
[00:26:25] Jill: Really strict
[00:26:26] Sadie: controlling.
[00:26:27] Jill: Gotcha.
[00:26:27] Sadie: Yeah. Can you kind of explain what each of those look like, especially when a child is struggling, and what the almost, like, negatives can be of either being really lenient or really controlling?
[00:26:40] Jill: Sure. A more authoritarian parenting style, it might work for some kids, but for many kids with powerful emotions, it looks like a lot of punishment and consequences.
[00:26:52] So it might look like, "I'm taking away your phone for a month. You can't go out for a very long time. I'm taking away TV. I'm taking away your activities." It can be punishment-driven and harsh, longer punishments, and it can also be critical, critical of people's emotions. So what that does is it often has people hiding or sneaking to try to get or do the things they desperately want to do, and it doesn't really teach them new behavior, and it often makes them withdraw and feel more distant from that parent, rather than having the effect of sort of scaring them into behaving, if you will.
[00:27:35] It doesn't solve the problem. And then on the overly lenient side, that cannot be helpful because sometimes it's not having standards that we want our kids to live up to, and it doesn't- Yeah, it's almost lowering our standards and also it can be lowering supervision. "Go out and do what you want. I just want you to feel good.
[00:27:56] I just want you to be happy," but not holding them accountable for homework and chores and household responsibilities and things like that. So either extreme cannot be as effective for the adolescent, and we know that authoritative parenting is the style that's kind of right in the middle, where you do have high standards, rules, guidelines, and expectations in the home, and structure, and you're aware of your adolescent's whereabouts and activities, and at the same time, it's kind of a democratic environment where you allow back-and-forth communication, negotiation, compromise, and you're also warm and nurturing while you have rules and structure.
[00:28:41] And we know from decades ago from Baumrind's research on authoritative parenting that that type of parenting has the best outcomes in kids across the board, so we try to teach parents that.
[00:28:53] Sadie: The family piece is so important and it really made all the difference in my own recovery. Families were, like, very involved at 3East with doing, like, the parent group together and family therapy and a lot of resources and support alongside what the teen was getting.
[00:29:11] Jill: Yes.
[00:29:11] Sadie: And after 3East, I spent time at a therapeutic boarding school where there's, like, family involvement, but Very different from what you see in DBT where it's like we have this whole module dedicated to like how we as a family can-
[00:29:25] Jill: Yeah ...
[00:29:26] Sadie: work together on this middle path and it's very integral to the, uh, goals you're working towards and a really big part of what success looks like in, in therapy and in building your life worth living.
[00:29:38] And so I'm curious why in the troubled teen industry side of things there's not that family involvement when it is so important and logically we know like, yeah, this kid is spending so much time with these people. It's so- Right ... important for their development.
[00:29:54] Jill: Right.
[00:29:54] Sadie: Why would that not be emphasized and as relevant and top of mind?
[00:29:59] Jill: Yeah, we see this a lot and even within some DBT practitioners that are hesitant to use the multi-family group model- Mm ... where adolescents and teens learn the skills together and are also hesitant even I would say sometimes phobic of doing family sessions- Mm ... because of how they can blow up. The family sessions get challenging and a lot of teens in the beginning say, "I am not going to a group if my- Yeah
[00:30:22] parents are there. No way. Are you kidding me? That's the last thing I'm gonna do." And people want to respect adolescents growing autonomy and independence and many believe that this is a developmental stage where teens need privacy and they need to do things more on their own, and there's validity to that.
[00:30:43] In our worldview though, in adolescent DBT, individual therapy is for that, right? Individual therapy is private. Then they are living in this environment which is, other than school, their principal environment, and they can get better so much more quickly if the skills generalize to the parents and if we improve the relationships directly.
[00:31:05] Sadie: Mm.
[00:31:06] Jill: So the key is, 'cause a lot of kids still come into my office and say, "I'm not... What? A multi-family group? So let me get this straight. I'm not only supposed to talk and share what's going on with my parents in the room, but with other people's parents in the room? Are you crazy?"
[00:31:22] Sadie: Yeah.
[00:31:23] Jill: And so it's really about orienting before they start.
[00:31:27] We don't just throw them in and say- Your
[00:31:29] Sadie: first day, surprise ...
[00:31:30] Jill: right. And so it's orienting and it's making it optional. They have to choose it. DBT was always intended to be a voluntary treatment and it's really not gonna work if the kid feels coerced by parents. So we want the kid to get on board and the kids who are reluctant to be with parents in their treatment in any form- I often ask them what they wish were different in their parents.
[00:31:54] "What do you wish your parents understood better about you? How do you wish they behaved differently? Here are the five problem areas, and here are the five skills modules we teach. Do you think your parents could benefit from learning any of these skills? How about understanding you better? How about their own focused attention?
[00:32:12] How about their own emotion regulation, et cetera? How about their interpersonal effectiveness, how they talk to you? Do you wish that would go better?" And almost every teen says, "Check, check, check. Yes, for sure. I'm all signed up. They need this therapy." So that-
[00:32:28] Sadie: Can they just do the DBT without me?
[00:32:30] Jill: Yeah. No, they, many people will say that.
[00:32:34] And so we'll say, "We understand you wish your parents could be better, could do it better, and could understand you better, and we don't know any better way to do it than have them learn the skills alongside you in skills group, and also to have some family sessions where we address some of the, the conflicts or the ways you don't see eye to eye head-on, just directly.
[00:32:55] Here's how we're gonna get your parents to buy in, here's how we're gonna get them to change in the ways you want, and here's how we're gonna get them to really understand you. They could do therapy on their own. There's parent therapy out there, but if they don't do it with you, they're not gonna get to know you better.
[00:33:11] They're not gonna get you better. Parent therapy alone won't be attuned to you. When we know your whole family system and see you in all these different settings, we can help you in the fastest, most effective way that's really gonna work."
[00:33:26] Sadie: Yeah.
[00:33:26] Jill: And plus, we tell them, "Skills group is not a group where you share all your deepest, darkest secrets.
[00:33:32] Skills group, it's a, like a class."
[00:33:34] Sadie: Chain analysis for why you didn't fold your laundry. Mm-hmm. Yeah. Like, it's not like-
[00:33:37] Jill: No ... let's
[00:33:37] Sadie: unpack a
[00:33:38] Jill: really deep thing. We have to really say what it is. Yeah. It's a class. It's like a class on emotions. We coach you, we teach you, we do fun practices, we show videos. We have a lot of laughs in there.
[00:33:48] So then we often get them on board, and I think sometimes the mistake people might make is they almost take adolescents at their word as though they're the experts. And of course, we always say people are the experts on their own lives, and that's true, and parents are the experts on their kids. But as DBT experts, we're trying to bring them a new perspective, a new lens of how to get better in a way that they might not initially feel comfortable and might not have been what they were planning or thinking.
[00:34:19] Yeah. But when we explain why, it usually makes sense, and the vast majorities of adolescents will do it when you just take the time to orient and then get their buy-in and then get their commitment and let them know they have a choice. "You're free to choose this." And then you usually get, "Well- All right, I guess I'm willing to try.
[00:34:38] I'm willing to come back next week- Yeah ... and hear more, or I'm willing to try.
[00:34:42] Sadie: Yeah. Yeah, it's really hard to get from what you described in the beginning of our conversation from a teen who's like, "All these people are telling me that I'm doing something wrong, and I just need to try harder," and the onus really being on how they're approaching things and how that might not be right and how the outcome could be different to being like, "Let us help you."
[00:35:03] Have these people that are really integral in your life better interact with you. Like, let's help teach your parents to understand you more and set a boundary in a less conflict-related way, and remind you when things might be getting challenging, but not in a way that's, like, calling you out or ineffective.
[00:35:25] I think it's really hard to communicate, especially when they've kind of been navigating life entirely alone or feeling very isolated in that experience. And so looping in a therapist or navigating the dynamics of group therapy can be very foreign and of cour- like, you've never done it before. Of course it makes sense that they're a little bit aversive and a little bit nervous about trying that out and taking that step.
[00:35:53] Jill: Absolutely makes sense. Yeah.
[00:35:55] Sadie: I mentioned that I did a long period of time in intensive treatment. I spent 14 months away from home, and obviously, that was really necessary at points. Like, I, I wasn't safe. I wasn't getting the support that I needed. And with that meant a lot of autonomy wasn't there. For over a year, I didn't take my own meds daily, or I wasn't in charge of, like, here's your routine, or go out and make friends and meet people.
[00:36:22] It's like, no, you live in this structured pseudo-treatment environment where it's like meals are at this time, and you live with people, so you naturally make friends, and you're doing group therapy together, so relationships are a lot more structured in the way that they develop versus if you were on your own.
[00:36:36] That is really different from the skills that you need to be able to thrive independently and on your own, and eventually, when you move out and are living without that structure, whether it's professional support or just from your parents and your family. How do you protect a teen and give them support and scaffold that recovery without teaching them that they can't survive their own life, or they can't navigate things on their own?
[00:37:05] Jill: Yeah. First of all, I love the fact that you, you did all that intensive treatment, and now you're devoting your time to these podcasts to spread the word about mental health and recovery and DBT. I think there are skills to be developed even, you know, certainly in a setting- Yeah ... like that. But how do you scaffold them?
[00:37:25] And, you know, within DBT, we have phone coaching, of course, to help with generalization so that when they're out there, when kids are out there living their lives and facing those tough moments, they can call for coaching so that they have a skillful response instead of using their go-to responses, which may be maladaptive, ineffective, self-harm, and other things.
[00:37:47] And then usually over time in the course of a treatment, the phone coaching frequency fades as kids have generalized the skills. That's why we give homework to do every single week, so they're always taking skills that they're learning and applying them out there in their lives. It doesn't do any good to just master them in a group setting or talk about them in individual.
[00:38:09] We're always giving homework and following up in detail on that homework, and giving coaching and feedback to be sure that every skill and every module we teach, they really have the skill down, so they're developing more and more capabilities. And even though we're validating the hell out of them and supporting them a lot as they go through so they feel understood and regulated and motivated, we really support change and have expectations of change, and kind of always drag new behaviors out of them.
[00:38:44] We have an expression called dragging out new behaviors. It's activating new behaviors even in every session. So we're not just talking about what life is like out there. We're having them do new behaviors, engage in new behaviors, and then also take those behaviors on the road, take them out into their lives where they need them most.
[00:39:06] And then what starts to happen is not only does a sense of mastery increase, but they get naturally reinforced by the environment. I mean, people come in and tell me, "My parents are so much different now, but I approached them this way, and then they were more validating than they've ever been, and we had a great night."
[00:39:22] Mm-hmm. Or, "My friends were better," or, "School went better." So they get natural reinforcers that starts to maintain some of those more effective behaviors out there in the world in their lives, but we have to help them and support them a lot in the beginning with all of these modes of treatment.
[00:39:42] Sadie: Yeah.
[00:39:43] You've worked with so many families who are struggling and so many teens who are in crisis or in a really rough chapter of their life. What gives you hope based on what you've seen in your work and all the research and, and practice that you've done over the years?
[00:39:59] Jill: Yeah. So inside my practice, I see the change in families.
[00:40:04] When we have graduations for families, when they complete the modules and they're ready to graduate from DBT, we always do a graduation ceremony in skills group, and we have families that came in, in so much stress, such high conflict, maybe shut down, not even speaking to each other, or just absolutely hopeless and lost.
[00:40:25] And almost every graduation is tearful teens and parents saying how this treatment changed their life, absolutely changed their life and saved their family. They often use that expression, "Not only saved my kid, but saved our family." And the adolescents are so grateful to their parents. The parents are so grateful to the group members and the adolescents.
[00:40:53] But not only what they say at graduation, but how they do it differently along the way. Family sessions start to look different. The communication is different. The kid looks different. We see kids who go from really despair to, you know, happy and excited and engaged in their life. People who were withdrawn and not having friends and just alone in their rooms, who are connected to school, connected to school activities, actually going out and seeing people in person, making friends, starting to date, or do other very developmentally appropriate things.
[00:41:30] Their emotions are so different. They look different. They hold themselves differently. And the family is all speaking the language of skills And wise mind and all of this terminology, we teach them, but they really, it becomes an automatic way of life for them. So there's that, and we see it just again and again and again after decades now actually.
[00:41:53] And then out there in the world, you know, when Alec Miller and I started doing this in the '90s, it was just for a handful of families in the Bronx. And now DBT and DBT for adolescents has become this worldwide treatment. People all over the world are really interested in learning DBT and practicing DBT, and that gives me so much hope because mental health stigma has gone down.
[00:42:20] The other thing that gives me hope is actually very soon, on October 28th at 1:00 in the afternoon, we're having the first World DBT Summit, and it is an international online summit, a conference where people are coming together, practitioners, researchers, and family members, clients of DBT, consumers, people who've been in DBT, people with lived experience are all coming together with a 24-hour marathon conference.
[00:42:55] And Alec Miller and I are doing a workshop on adolescent DBT and the caregiver role specifically in adolescent DBT. Marsha Linehan herself got this effort started years ago, the idea of having a World DBT Association where everyone is working together to share resources, research, get people trained, and get the word out to families who so desperately need this.
[00:43:17] And this upcoming summit is one major way we're doing it, but there are also many other efforts underway.
[00:43:25] Sadie: Amazing. And if people want to connect with you and follow along with your work or are potentially in your area and looking for resources, where can they do that?
[00:43:35] Jill: Through my practice at Cognitive Behavioral Associates in New York.
[00:43:39] It's cbtreatment.com. All the resources and my information is there, my team's information is there for treatment and also training and consultation. And also we have online courses through PsychWire where people can get trained in adolescent DBT in both the individual therapy and the skills component in depth in a self-paced online format.
[00:44:04] Sadie: Amazing. Well, thank you so much for joining me today.
[00:44:07] Jill: Thank you so much for having me. It's really been a pleasure.
[00:44:10] Sadie: If you enjoyed this episode of She Persisted, make sure to leave a review, subscribe, and share with a friend or family member. Follow along at @shepersistapodcast, on TikTok, Instagram, YouTube, and more for bonus content.
[00:44:20] Thanks for listening and keep persisting