‘The best tool we have’ for self-harming and suicidal teens

Studies indicate that dialectical behavior therapy offers greater benefits than more generalized therapy but treatment is intensive, and expensive. (Photo: NYTimes)
Parents seeking therapy for teenagers who self-harm or have anxiety, depression, or suicidal thoughts face an imposing thicket of treatment options and acronyms: cognitive behavioral therapy (CBT), parent management training (PMT), collaborative assessment and management of suicidality (CAMS), acceptance and commitment therapy (ACT), and others.اضافة اعلان

Each approach can benefit a particular subset of people. But for teenagers at acute risk for self-harm and suicide, health experts and researchers increasingly point to dialectical behavior therapy, or DBT, as an effective treatment.

“As of this moment, it’s probably the best tool we have,” said Michele Berk, a child and adolescent psychiatrist at Stanford University.

In a 2018 study in the Journal of the American Medical Association, Berk and her colleagues found that DBT led to sharper drops in suicidal attempts and self-harm among adolescents than a more generalized therapy did. A 2014 study by researchers in Norway found a similar effect, noting that the therapy also has a relatively low dropout rate, and concluded that “it is indeed possible for adolescents to be engaged, retained and treated” using DBT. The therapy is also identified as a key evidence-based treatment by the American Academy of Pediatrics. If anything, Berk said, DBT “is not available enough.”

How DBT works
DBT is a subset of CBT, which aims to reframe a person’s thoughts and behavior. DBT focuses initially on behavior and raw emotion, helping the individual surmount moments of crisis and understand what prompted the behavior in the first place.

DBT is intensive. The fullest version of the program, which can take six months to a year to complete, has four components: individual therapy for the teenager; group therapy; training for teenagers and their parents to teach emotional regulation; and phone access to a therapist to help during a crisis.

The initial step is to teach a patient to recognize the feelings in the body when dangerous impulses arise, like “a lump in the throat, racing pulse, tense shoulders,” said Jill Rathus, a psychologist practicing in Long Island, New York. In the 1990s, Rathus was part of a team that adapted the adult version of DBT for use by adolescents and their families.

Patients then learn to put those feelings into words. It is vital, Rathus said, to “put language” to a physical and emotional experience; this engages parts of the brain, like the prefrontal cortex, that help regulate emotions. In young people, these brain regions are not fully developed and can easily become overwhelmed.

The next step is to learn to lower the arousal state with specific, often simple techniques: splashing the face with cold water, doing brief but intense exercise, putting an ice pack on the eyes — to “tip the body chemistry,” in the language of DBT.

Not without a cost
Therapists trained in DBT can be expensive and hard to find, and are often booked solid.

In the US, rates vary by state and provider, but clinicians said it is not uncommon for a single hour of individual counseling to cost $150 to $200 or more, with group therapy roughly half that cost. Over six months, treatment can cost as much as $10,000 for someone paying out of pocket.

Anthony DuBose, head of training for Behavioral Tech, an organization that trains DBT therapists, said that the relative scarcity of DBT counseling, among other reasons is that some therapists fear that the therapy is too intensive and might overtake their available time. “We need to convince mental health providers they can do this,” he said.

Various versions
Slimmed-down versions of DBT exist, and they may also work for adolescents experiencing self-harm and suicidal tendencies, experts said. But, these experts cautioned, many of these emerging variations have not been studied with the same rigor as the fuller treatment.

Anecdotally, adolescents who have had some DBT or CBT training appear better equipped to deal with distress and suicidal feelings, according to Dr Stephanie Kennebeck, a pediatric emergency room doctor at Cincinnati Children’s Hospital who has researched therapeutic approaches to suicidal impulses.

Kennebeck said she had witnessed the value of the training firsthand in cases when adolescents arrived at the emergency room overcome by their intense emotions. Teenagers who had not had therapy and had no training to fall back on often needed to be kept at the emergency room longer, until they could be placed in a treatment program, Kennebeck said. She added that she felt more comfortable sending a child home if they had some sense of how to navigate difficult emotional situations.

“Those patients who have already had some CBT or DBT have the ability to name what their emotion is, tell me how their emotion can translate into what they’re going to do next,” Kennebeck said. “That is invaluable.”

There are many therapeutic models that help address different emotional issues including anxiety, depression, and trauma. When acute behavioral risk, like self-harm and suicide, is a concern, the American Foundation for Suicide Prevention recommends a number of options beyond DBT, including CAMS, which has been shown in studies to be effective at reducing suicidal thoughts, and cognitive behavioral therapy for suicide prevention, or CBT-SP, which has been shown in studies to be effective in preventing further suicide attempts in adults with at least one prior attempt.

Therapy for parents, too
In DBT, the adolescent is not the only one learning. Parents are trained to validate the feelings of their teenagers, as irrational as those feelings may seem.

“The mistake parents make, even well-meaning and loving parents, is to minimize the feelings,” Rathus said. Telling a distraught adolescent “to just go for a walk, or focus on schoolwork, is like telling them to climb Everest.”

She said that the adolescent cannot hear the words, and they quickly “learn not to trust” strong feelings or emotions. Parents take group classes in which they are guided to understand what teenagers are going through and are taught specific ways to address the distress.

Valerie, an executive in Silicon Valley, described her family’s experience with DBT. (She asked that her last name not be used to protect their privacy.) Midway through 2021, Valerie’s 12-year-old daughter grew increasingly distraught; once a solid student, she began acting out in school, had seemingly uncontrollable meltdowns, and became obsessed with her appearance and weight.

The girl started DBT, and Valerie took the parental instruction, which taught her more effective ways to respond to her daughter, she said — for instance, by first validating the girl’s painful feelings rather than immediately proposing a solution.

If her daughter is afraid to deal with a difficult subject or teacher in school, Valerie tries to reframe the fear: “I’ll say, ‘OK, you’re going to have this bad experience. So, beforehand, get some good sleep, have some good snacks, arrange to meet a friend after, bring a little fuzzy bear to class.’”

Valerie added: “It’s like filling up your gas tank before you go on a long trip.” She said the concepts were ones she had begun to adopt in her own life as she examined “worry thoughts,” such as, “Will I be lonely after I sell my business?”

She said that her daughter was improving. “It’s helped her get out of feeling hopeless or stuck in things,” Valerie said. “She’s catastrophizing things less” and “no longer going down rabbit holes she can’t get out of.”

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