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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