Three DBT Skills To Help a Suicidal Teen
Living in the Kootenays, we are isolated from acute care facilities that help teenagers who struggle with serious mental health issues. The closest adolescent psychiatric hospital is in Kelowna; the closest eating disorder hospital is on the coast. If a teenager struggles profoundly with a mental health issues like suicidality or anorexia, they must leave their home community in order to receive the help they need.
We need more resources closer to home for rural teenagers. Not only is it less disruptive, if we’re talking dollars and cents it is also less expensive. With better supports in local settings, communities can gather and help teens further upstream. Dialectical Behaviour Therapy, or DBT, is one such resource.
Dialectical Behaviour Therapy was originally designed to help profoundly suicidal patients within hospital settings. As the name suggests, at its outset DBT was a behaviour therapy, meaning that its approach was to change ‘problematic’ behaviours. However, the pioneering patients of the therapy felt that they were being moved too fast into changing their behaviours. As a result, DBT was modified to be based on acceptance and change. A key tenet of DBT is that one must first accept reality as it is – totally and completely – before even beginning to contemplate change.
I sometimes get calls from concerned parents, psychiatrists, and other helpers looking for DBT support specifically for teens. It’s a good fit: teens often struggle with regulating emotions, relating with parents, impulsive behaviours and so forth – all of which DBT addresses. While it is often delivered in a group setting, there is no such resource for teens in the West Kootenays. The good news is, DBT skills can also be utilized on a one-to-one basis. There’s even a great DBT book for adolescents. It’s full of skills and activities to work through alone or with another. Below are three skills that can help teens who struggle with suicidal ideation. The last one – TIPP – is specifically for when crisis feelings are high.
Many of us know how it feels when our truth is not validated from the outside. On the emotional level, it doesn’t matter very much whether other people’s intentions are kind or hurtful: a feeling of invalidation leads to isolation. If the pain is too great to bear, it can turn to suicidal thoughts and behaviours. The founder of DBT, Marsha Linehan, outlines some of experiences that lead to painful invalidation:
1. Being ignored.
2. Being repeatedly misunderstood.
3. Being misread.
4. Being misinterpreted.
5. Having important facts in your life ignored or denied.
6. Receiving unequal treatment.
7. Being disbelieved when being truthful.
8. Having private experiences trivialized or denied.
For many teenagers, being misunderstood is quite common. Feelings of injustice can arise when perspectives are ignored, or when teens differ from their caregivers on the best way to guide them. It is a difficult time of life. Power dynamics shift and they often see things differently than the adults in their lives. Whether or not teenagers find support and validation on the outside, there are skills by which they can self-validate. These include:
1. Being non-defensive and checking the facts of a situation. Are your responses valid, or have you misunderstood another’s intentions? If you have someone in your life that you trust, check your responses with them.
2. Acknowledge when your responses don’t make sense, and drop blame – it rarely helps.
3. Be kind to yourself. Remind yourself that you are doing your best (just getting through the day can be a heroic accomplishment).
4. Admit that it hurts to be invalidated by others.
5. Grieve traumatic invalidation and the harm it creates. If you have a trusted person in your life, share it with them.
Radical acceptance is a superstar of the DBT world. In a nutshell, what it means is this:
It is what it is.
Oftentimes, the pain we experience is exacerbated by the idea that if we could only make it different somehow, things would be better. We don’t like the present moment. We hate the way things are. As unpleasant as things may be, however, if we rail against the reality of it we only increase our suffering.
The word radical has its origin in the Latin word radix, or ‘root’. What it means in this context is to go all the way to the root of acceptance – totally and completely. In radical acceptance there’s no “Yeah, but…” It’s complete acceptance, all the way, even if the situation sucks.
Sometimes people think that acceptance means saying that something is okay, even if it is intolerable. That’s not what is meant here. It means is that even if the situation is unacceptable – say, sexual abuse for example – radical acceptance simply states that it is what it is. It doesn’t cancel out problem solving or change. It just means that we have to allow that the bad/uncomfortable/painful thing happened/is happening/might happen.
When a person is in crisis, these are the skills to use. The human nervous system consists of both the sympathetic and parasympathetic nervous systems. The first stimulates arousal; the second calms us down. All of the TIPP skills work to stimulate the parasympathetic nervous system. These skills don’t replace the problem solving; they calm us down enough to begin to think of solutions.
The ‘T’ stands for changing your facial temperature with cold water, while holding your breath. This activates the dive reflex, which reduces physiological and emotional arousal. For those who are unfamiliar, the dive reflex causes the heart rate to slow down to below resting heart rate in mammals when they are immersed in very cold water without oxygen. A great way to do this is to fill a sink with very cold water and ice if it’s available, and then immerse your face for as long as you can hold your breath.
Caution: please avoid if you have heart problems. There are other skills you can use in a crisis.
2. Intense Exercise
The ‘I’ stands for intense aerobic exercise for at least 20 minutes. Not only does intense exercise increase positive emotions, it also helps to shake off unpleasant ones. According to DBT, emotions help to organize the body for action. For example, anger cues the body to fight, while fear cues us to run. Sometimes emotional reactions are not useful and can even make a situation worse. Exercise can help us discharge the energy of the emotion without causing any harm.
3. Paced Breathing
The last two TIPP skills are less vigorous and better for people who, for whatever reason, should avoid extreme physical states. Paced breathing includes slowing the breath down to 5 or 6 breath cycles per minute, and breathing deeply from the abdomen. The outbreath should be longer than the inbreath. This longer outbreath stimulates the parasympathetic nervous system, which in turn calms the body down.
4. Paired Muscle Relaxation
With this skill, the strategy is to tense muscle groups while breathing in, and then to relax the muscles on the outbreath while silently saying “Relax”. This skill teaches a person to notice the sensations of tensing and relaxing, and also allows for greater muscle release by tensing first. Pairing it with a word (the word can be anything calming) also brings a different level of awareness to the calming intention.
This is a “quick and dirty” rundown of some DBT skills to help teens work through suicidal thoughts and behaviours. It is by no means exhaustive, and is meant to complement rather than replace a safety plan. If you know (or are) a teen who is suicidal, make sure that there is a trusted someone to reach out to – be it a friend, a caregiver, or a counsellor. There is a 24/7 crisis line to access, and you should know where the nearest emergency room is as well. If all other supports fail, this is the place to go, any time of the day or night.
It is sometimes said that suicide is a permanent solution to a temporary problem, and I really do believe this to be true. It can be hard to believe that things will get better – especially when you have relatively little life experience with which to compare your current situation. The beautiful thing about getting help young is that the earlier someone gets help, the better the outcome – even going into adulthood. So don’t be afraid to reach out – there is help, hope, and healing available. Feel free to be in touch if you have any questions. In health and wellness, Deirdre.