Insights

A toolbox for hope 

September is Suicide Prevention Awareness Month.  Fall is a difficult time of year for many young adults.  Can a specialized therapy help them year-round?

In a 2022 New York Times article on a topic deeply painful for any parent, we learn that Dialectical Behavior Therapy (DBT) is considered the most effective evidence-based therapy for a teen’s self-harming and suicidal behavior. DBT is intensive, requires a significant commitment of time and resources, including parent training, and qualified DBT therapists can be hard to find. But nested inside the article is reason for optimism. Teens can learn concepts and skills to head off or recover from crisis and block impulsive behaviors. The same skills can also help them grow into resilient, thoughtful and caring adults.

“‘The best tool we have‘ for self-harming and suicidal teens.”  (New York Times, August 30, 2022)

• Why is DBT so effective?
• How can parents weigh the costs against the long- term benefits of DBT?
• Where can families turn to learn more, including programs for teens?

–A subset of Cognitive Behavioral Therapy originally developed by Marsha Linehan for adults with Borderline Personality Disorder, DBT has proved to be an effective tool for mood disorders, substance use, eating disorders and PTSD.

–The goal of DBT is to reframe thinking that leads to dysfunctional behavior by learning concepts and practicing skills – mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance. Skills are reinforced by the DBT therapist who also acts as coach.

–A modified version of DBT for teens with chronic emotion dysregulation and self-harming behaviors teaches them “safe and positive ways to cope with their negative emotions.”

-Teens learn to use language to label their feelings. Dr. Jill Rathus, a clinical psychologist who helped create the adolescent version of DBT, notes: “It is vital to ‘put language’ to a physical and emotional experience; this engages parts of the brain, like the prefrontal cortex [not fully developed in teens], that help regulate emotions.”

–Parents play a vital role as an ally, not an adversary, by learning and reinforcing skills and validating their teen’s feelings, often opening a positive new chapter in family dynamics.

-DBT is compelling because it teaches strategies applicable throughout life, regardless of age or context – self-awareness, navigating difficult social situations, managing intense emotions, taking the perspective of others, deflecting a crisis mindset when triggered or uncomfortable.

–DBT therapy should be viewed as a family’s proactive step to stop the cycle of chronic life crisis, often leading to recurring ER visits and inpatient treatment, disrupting their teen’s education and having a negative impact on their overall health, important relationships, jobs and even future career path. DBT is an opportunity to create a new paradigm for engaging with self and the world that has lifetime cost benefits. 

–DBT gives us hope for a holistic approach to treatment for young adults who are by nature eager to learn and happiest when connecting with others.

–Due to widespread demand, DBT outpatient programs for youth and DBT-trained therapists are increasing in numbers, many offering telehealth.

Helpful Resources

What is Dialectical Behavior Therapy for Adolescents? | YouTube video, UCSF

McLean Hospital

• Dialectical Behavior Therapy: Your Toolbox for Managing Emotions
• Everything You Need to Know about Child and Teen Mental Health
• 3East Adolescent DBT Programs – overview

American Foundation for Suicide Prevention

• Therapies for Suicide Prevention

Excellent overview of DBT and other therapies effective in reducing suicidal and self-harming behavior.

Stanford Medicine | Department of Psychiatry and Behavioral Sciences

• RISE: A 12-week DBT Intensive Outpatient Program for Teens
• Adolescent Dialectical Behavioral Therapy – overview of DBT for adolescents 

Your health information absorption rate

Some decisions about your health are straightforward, black-and-white choices, a simple box to check with the prospect of a certain outcome. Decision-making confidently about challenging health-related matters is when things get tough. A good advocate understands this and is your partner.

One of the most important roles an advocate plays is health information management. We can slow down the firehose of medical information coming your way, apply the brakes to give you time to absorb and process what you’re hearing and make sure important decisions aren’t rushed. A good advocate can break down difficult health concepts into manageable chunks and translate for you – or others in your circle – testing for understanding along the way. 

 Our family’s first pediatric endocrinologist, arguably one of the best to ever practice, was a master in this skill and taught me an indelible lesson. Wearing a Disney-themed tie and greeting us in the hallway of the emergency room at Boston Children’s Hospital for the first time, I asked him the first question. “Diabetes… is that from the liver or the kidney?” His reply: “Your daughter’s pancreas has stopped working but I don’t want to overwhelm you right now. Let’s start slowly.”

A good advocate understands this – and can even ask your doctor to slow things down or ask for a pause, making space for you to ask, “What is essential to know now, and what can wait?”

“A safety pause was observed” 

Following a recent medical procedure I reviewed the clinical notes in my medical chart. I read an important sentence that started, “A safety pause was observed before the procedure began.” I am a big fan of Dr. Atul Gawande – author, skilled surgeon and pioneer in patient safety – and was happy to see one of the core principles of his Checklist Manifesto guiding my care in a Boston hospital. Reading this in my chart made me feel more reassured and confident about my outcome and comfortable in the patient experience.

I also had an epiphany of sorts about my role as health navigator and patient advocate. Gawande’s checklist describes an important part of what we do – create the equivalent of a safety pause for our clients facing health decisions.

According to Dr. Gawande, an ideal checklist for any procedure – whether a medical procedure or troubleshooting an aircraft’s unstable flight – is precise, concise, practical, clarifying and efficient. In a medical context, it builds patient (and clinical team) understanding, clarifies priorities and fosters communication. Checklists in medical procedures include key decision points calling for a safety pause to confirm critical steps to proceed safely- and ensuring everyone is on the same page. A checklist is not a how-to guide but a tool to guide your work. In this way a checklist shifts decision-making from a single, centralized authority to a highly collaborative process focused on a common goal: the best patient outcome.

I realized that this safety pause and checklist approach describes my approach and core practice principle. I create pause-and-think points in the healthcare experience for clients, allowing them to clarify their priorities, understand next steps and feel reassured that health decisions align with their goals. I act not as a how-to guide but a tool to guide our work. I build patient understanding, clarify priorities and foster communication.

I have always found process and an orderly approach to thinking a source of comfort and hope I can share this with you, too.

Thank you, Dr. Gawande.

To learn more:
http://atulgawande.com/book/the-checklist-manifesto
Atul Gawande