‘The Best Tool We Have’ for Self-Harming and Suicidal Teens

Original article written by Matt Richtel for the New York Times


For teenagers at acute risk for self-harm and suicide, health experts and researchers increasingly point to dialectical behavior therapy, or D.B.T., as an effective treatment. “As of this moment, it’s probably the best tool we have,” said Michele Berk, a child and adolescent psychologist at Stanford University.


In a 2018 study in the journal JAMA Psychiatry, Dr. Berk and her colleagues found that D.B.T. led to sharper drops in suicide 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 D.B.T. The therapy is also identified as a key evidence-based treatment by the American Academy of Pediatrics. If anything, Dr. Berk said, D.B.T. “is not available enough.”


So what is D.B.T.? Dialectical behavior therapy is a subset of cognitive behavioral therapy, which aims to reframe a person’s thoughts and behavior. D.B.T. focuses initially on behavior and raw emotion, helping the individual surmount moments of crisis and understand what prompted the behavior in the first place.


D.B.T. 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. In the 1990s, Dr. Rathus was part of a team that adapted the adult version of D.B.T. for use by adolescents and their families.


Patients then learn to put those feelings into words. It is vital, Dr. 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 D.B.T.


Therapists trained in dialectical behavior therapy can be expensive and hard to find, and are often booked solid. 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. But the out-of-pocket expense can also vary widely depending on the type of insurance plan being used, and whether or not the treatment is covered by Medicaid, the state insurance plan.


Only two states — Minnesota and Missouri — provide broad support for D.B.T., according to Anthony DuBose, the head of training for Behavioral Tech, an organization that trains D.B.T. therapists. He cited another reason for the relative scarcity of D.B.T. counseling: 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.


The up-front costs can be worth it in the long run: Several studies compiled by researchers at the University of Washington suggest that D.B.T. interventions, while initially costly, can reduce the need for expensive, repeated emergency room visits. According to the university’s Center for Behavioral Technology, D.B.T. is cost-effective, and “accumulating evidence indicates that D.B.T. reduces the cost of treatment.”


Anecdotally, adolescents who have had some D.B.T. or C.B.T. 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.


Dr. 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, Dr. 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 C.B.T. or D.B.T. have the ability to name what their emotion is, tell me how their emotion can translate into what they’re going to do next,” Dr. Kennebeck said. “That is invaluable.”


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