Dr. Nolan Grayson

Dr. Sloan Bruan Lorenzini

Welcome to the Sloan Continuing Education podcast. I'm Dr. Sloan Bruan Lorenzini, and today I'm speaking with Dr. Nolan Grayson, a board-certified child and adolescent psychiatrist who has spent the last fifteen years adapting Dialectical Behavior Therapy for adolescent populations. He runs one of the few comprehensive DBT programs in the country designed specifically for teens, and he trains clinicians nationally on this work. Dr. Grayson, thank you so much for being here.

Dr. Nolan Grayson

Thank you, Sarah. It's always a pleasure to talk about this work. Adolescent DBT is something I'm deeply passionate about, and I think there's a real hunger in the field right now for practical guidance on how to do it well.

Dr. Sloan Bruan Lorenzini

Let's start with the big picture. Why does standard DBT need to be adapted for adolescents?

Dr. Nolan Grayson

Standard DBT was developed by Marsha Linehan for adults with borderline personality disorder, and it's a brilliant framework. But when you're working with a fifteen-year-old, you're dealing with a fundamentally different clinical picture. The developmental context is different. Their identity is still forming, their prefrontal cortex is years away from full maturation, and they're embedded in family systems and school environments in ways that adults simply aren't. You can't just take the adult manual and hand it to a teenager.

Dr. Sloan Bruan Lorenzini

So it's not just simplifying the language. It's a deeper structural change.

Dr. Nolan Grayson

Exactly. Alissa Miller and Jill Rathus did groundbreaking work on DBT-A, the adolescent adaptation, and what they recognized is that you need to shorten the treatment frame, bring families into the skills group, and add a fifth module called Walking the Middle Path, which addresses the dialectical dilemmas that are unique to adolescent-family dynamics. It's not a watered-down version of adult DBT. It's a thoughtful reconfiguration that respects where these kids are developmentally.

Dr. Sloan Bruan Lorenzini

Let's talk about distress tolerance specifically. How does a developing brain change how you teach those skills?

Dr. Nolan Grayson

This is where neurodevelopment really matters. Adolescents experience emotional intensity that is neurobiologically different from what adults experience. The amygdala is highly reactive, and the prefrontal cortex, which is responsible for impulse control and long-term planning, is still under construction. So when we teach distress tolerance, we need skills that are concrete, immediate, and sensorily grounded. TIPP skills work beautifully here because they target the body directly.

Dr. Sloan Bruan Lorenzini

Can you walk through how you introduce TIPP with a teen who's never done any skills work before?

Dr. Nolan Grayson

Absolutely. I start with temperature because it's the most visceral and the most immediately effective. I'll have them hold ice cubes or splash cold water on their face, and you can see the parasympathetic nervous system kick in almost instantly. For a teen who's been white-knuckling through emotional crises, that moment of physiological relief is powerful. It builds buy-in for the rest of the skills. From there, we move into intense exercise, paced breathing, and paired muscle relaxation. But I always frame it as building a toolkit, not memorizing a textbook. The teens who stick with DBT are the ones who feel like these skills actually belong to them.

Dr. Sloan Bruan Lorenzini

That toolkit metaphor is great. Let's shift to emotion regulation. What skills are you finding teens actually internalize?

Dr. Nolan Grayson

The ones that meet them where they are. ABC PLEASE is foundational, but you have to translate it into their world. Accumulating positive experiences doesn't mean journaling about gratitude for most teens. It means identifying what actually brings them joy and building structure around it. For a lot of my patients, that's time with specific friends, creative pursuits, physical activity. The skill is the same; the application has to be developmentally informed.

Dr. Sloan Bruan Lorenzini

What about opposite action? That seems like a particularly hard sell for adolescents.

Dr. Nolan Grayson

It is, and honestly, it should be a hard sell. If a teen takes to opposite action immediately, I'd question whether they really understand what we're asking. The whole point is that it's counterintuitive. What I've found effective is using behavioral experiments. Rather than saying "do the opposite of what your emotion is telling you," I'll say, "let's test the prediction your emotion is making." So if a socially anxious teen's fear is telling them that going to a party will be a disaster, we design an experiment. Go for thirty minutes, rate the experience, and compare it to the prediction. Teens respond to data about their own lives. It takes the moralism out of it and makes it empirical.

Dr. Sloan Bruan Lorenzini

That's a really elegant reframe. Now, interpersonal effectiveness in school settings. That must come with its own complications.

Dr. Nolan Grayson

School is the arena where these kids live, and it's relentless. They're navigating peer hierarchies, romantic relationships, conflicts with teachers, and cyberbullying, all within a system that doesn't always support their emotional needs. DEAR MAN, GIVE, FAST work well, but you have to role-play scenarios that are real to them. Asking a teacher for an extension, setting a boundary with a friend who's pressuring them, navigating a group chat that's turned hostile.

Dr. Sloan Bruan Lorenzini

Do you find that schools are generally cooperative when a teen is in DBT?

Dr. Nolan Grayson

It varies enormously, and that's a systemic issue we need to keep pushing on. Some schools are fantastic. They'll collaborate on safety plans, accommodate skills practice, and communicate proactively with the treatment team. Others are rigid or under-resourced, and the teen ends up stuck between the clinical recommendations and the school's expectations. I always try to get a release to communicate with the school counselor at minimum. When we can align the environments, the outcomes are significantly better. But I'm also realistic with families that we can't always control the school's response, so part of our work is helping the teen navigate systems that aren't perfectly supportive.

Dr. Sloan Bruan Lorenzini

Let's talk about the family component. In DBT-A, parents are in the skills group. What happens when the family system is actively part of the problem?

Dr. Nolan Grayson

That's the clinical reality more often than not. Very few families come in with perfectly regulated parents and one struggling teen. What you typically see is a transactional pattern where the teen's dysregulation and the parents' invalidation are feeding each other. The Walking the Middle Path module addresses this directly. We're teaching both sides dialectical thinking, validation skills, and behavioral change strategies simultaneously.

Dr. Sloan Bruan Lorenzini

How do you handle it when a parent is actively undermining the treatment?

Dr. Nolan Grayson

With radical genuineness and a lot of patience. I validate the parent's experience first. They're usually exhausted, frightened, and feeling blamed. If I can convey that I understand their suffering, I can often get them to engage with the skills rather than resist them. But I'm also direct. If a parent's behavior is functionally maintaining the teen's symptoms, I name that clearly, with compassion, but without hedging. The dialectic is that the parent is doing the best they can and they need to do better. Both things are true.

Dr. Sloan Bruan Lorenzini

Let's move to something clinicians often find challenging. Managing self-harm disclosures in a group skills training context.

Dr. Nolan Grayson

This is one of the most important clinical protocols to get right. In DBT, we're explicit from the outset that group is not the place for detailed disclosure of self-harm behaviors. The group agreement covers this in the first session. The reason is twofold. Detailed disclosure can be triggering for other group members, and it can inadvertently reinforce the behavior through social attention. That doesn't mean we shut it down harshly. We validate, redirect, and ensure the individual gets support in the appropriate modality.

Dr. Sloan Bruan Lorenzini

What does that redirection actually sound like in the moment?

Dr. Nolan Grayson

It might sound like, "I really appreciate you trusting the group with that. It takes courage. What I want to make sure is that you and I can talk about this in detail in our individual session this week, where I can give it the full attention it deserves. For right now, can you tell us what skill you used or what skill you wish you had used?" That keeps the focus on skills, respects the group norms, and communicates to the teen that they're heard without opening the floor to graphic detail. And I always follow up individually within twenty-four hours after a disclosure like that.

Dr. Sloan Bruan Lorenzini

That's very clear. Phone coaching with teens. I imagine this looks quite different from the adult model.

Dr. Nolan Grayson

Dramatically different. First, the obvious. Teens text. They don't call. So you have to decide upfront whether you're going to offer phone coaching by actual phone, by text, or through a secure messaging platform. I use a combination. For skills coaching in the moment, I'll accept brief texts during defined hours and then call back if the situation warrants it. The boundary piece is critical. You need a clear coaching agreement that specifies hours of availability, expected response times, what constitutes a coaching call versus a crisis, and what happens after hours. With teens, you also need to clarify the parents' role. Is the parent going to be the one texting on behalf of the teen? Can the teen contact you directly? What's the threshold for parental notification? I lay all of this out in writing during the orientation phase so there are no surprises. The other piece that's unique to adolescents is that many of them have never had an adult in their life who was available for real-time support in a boundaried way. The coaching relationship itself can be profoundly therapeutic, separate from whatever skill you're teaching in the moment.

Dr. Sloan Bruan Lorenzini

That's such an important point. Let's talk about outcomes. When you're measuring progress with teens in DBT, what actually matters?

Dr. Nolan Grayson

The gold standard measures are self-harm frequency, suicidal ideation, emergency department visits, and psychiatric hospitalizations. Those are non-negotiable to track. But with adolescents, I also look at school attendance, peer relationship quality, family conflict frequency, and skills use. Diary cards are the backbone of this. I use a modified adolescent diary card that tracks target behaviors, emotions, urges, and skills used on a daily basis.

Dr. Sloan Bruan Lorenzini

How compliant are teens with diary cards in your experience?

Dr. Nolan Grayson

It depends on how you frame it. If it feels like homework, compliance drops off fast. I present the diary card as their data, not mine. I'll say, "This is how you prove to yourself that things are changing." I also use digital diary cards when paper doesn't work. There are a few good apps now that make it more seamless. The key is reviewing the card together at the start of every individual session and making it central to the treatment. If you skip the card review, you're communicating that it doesn't matter, and the teen will pick up on that immediately. When the card is consistently used, you get a granular picture of progress that's far more informative than a pre-post questionnaire.

Dr. Sloan Bruan Lorenzini

Alright, let's do a quick lightning round. Favorite resource for clinicians learning adolescent DBT?

Dr. Nolan Grayson

The Miller and Rathus DBT Skills Manual for Adolescents. It's the definitive text, and it's clinically rigorous without being inaccessible.

Dr. Sloan Bruan Lorenzini

Best piece of supervision advice you've ever received?

Dr. Nolan Grayson

Watch your own consultation team behavior. If you're not practicing DBT in consultation, you're not doing DBT.

Dr. Sloan Bruan Lorenzini

Most common mistake new DBT therapists make with teens?

Dr. Nolan Grayson

Validating without pushing for change, or pushing for change without validating. The dialectic is the whole treatment. If you're only doing one side, you're doing supportive therapy or you're doing behavioral management. Neither of those is DBT.

Dr. Sloan Bruan Lorenzini

Any final thoughts for clinicians who are considering adding DBT-A to their practice?

Dr. Nolan Grayson

Get trained properly. DBT is not a set of worksheets. It's a comprehensive treatment model with specific structures, including individual therapy, skills group, phone coaching, and consultation team. If you're going to do it, do it right. Join or form a consultation team. Get intensive training from a recognized provider. And be prepared for this work to change how you practice entirely. Once you see what comprehensive DBT can do for a suicidal teenager and their family, it's very hard to go back to treatment as usual. The evidence base is strong, the clinical need is enormous, and the kids deserve our best effort.

Dr. Sloan Bruan Lorenzini

Dr. Grayson, this has been an incredibly rich conversation. Where can listeners learn more about your work and your training programs?

Dr. Nolan Grayson

They can visit our program website at graysonDBT.com for information on our adolescent DBT program and upcoming clinician training intensives. And of course, I'm always happy to connect with fellow clinicians who are doing this work. Thank you for having me, Sarah. This was a great conversation.