Advances in Pediatric Psychiatry

Dr. Casey O’Brien

Now, more than ever, teenagers are experiencing a mental health crisis, according to Casey O’Brien, PsyD, a clinical psychologist and Assistant Director of the Adolescent Dialectical Behavioral Therapy (DBT) Programs at NewYork-Presbyterian/Columbia. “[Data from the Centers for Disease Control and Prevention shows that] more than 1 in 5 teens are seriously considering suicide and 10% have attempted suicide,” says Dr. O’Brien. “Teenagers are transitioning from a world where many people made decisions and rules for them to a world where they need to advocate for themselves and make their own decisions and rules by which they will live. They start developing their own identity and values.”

At NewYork-Presbyterian/Columbia, child psychiatrists, psychologists, and other mental health clinicians provide state-of-the-art evidence-based treatment for childhood and adolescent psychiatric concerns and needs. One of those treatments is DBT, a form of cognitive-behavioral therapy that teaches behavioral and acceptance-based strategies to those experiencing emotion dysregulation.

“[Data from the Centers for Disease Control and Prevention shows that] more than 1 in 5 teens are seriously considering suicide and 10% have attempted suicide. Teenagers are transitioning from a world where many people made decisions and rules for them to a world where they need to advocate for themselves and make their own decisions and rules by which they will live. They start developing their own identity and values.” — Dr. Casey O’Brien

“Very often psychological treatments focus on acceptance or change. DBT says we need both: Accept ourselves, accept others, accept the world we live in, and at the same time actively put in effort to change our behaviors, change the way we relate to others, change the way we relate to the world that we live in, and/or actively change the world that we live in,” says Dr. O’Brien. “For example, if you are depressed, you want to accept that feeling depressed will make you feel less motivated to do things that bring you joy, to engage in activities and socialize. We want to accept and understand our vulnerabilities, so we know where we need to put effort.”

Tackling Tough Emotions

Emotion dysregulation can present in a variety of ways, including mood swings, impulsive behavior, mania, irritability, and more. “Sometimes we can develop a pattern where our behaviors or experiences are driven by our emotions, we feel, therefore we act,” says Dr. O’Brien. “We consider that emotional dysregulation because our emotions aren’t really changing with our experience or environment in ways that are wanted.”

NewYork-Presbyterian/Columbia offers a comprehensive outpatient adolescent DBT program for teens and families which includes individual therapy, multi-family skills group, and phone coaching. However, with the growing need for additional support for teens and families between inpatient treatment and traditional outpatient treatment, NewYork-Presbyterian/Columbia identified a need to offer a more intensive program for teens and families with high-risk behaviors or emotion dysregulation.

“We found that we needed an intermediary level of care between these high levels of care, where teens are living in a residential program or needing inpatient psychiatric hospitalization, and our outpatient DBT program. We also found that we needed programs that provided more intensive support, not just to the teens but also to their parents and guardians.” — Dr. Casey O’Brien

“We found that we needed an intermediary level of care between these high levels of care, where teens are living in a residential program or needing inpatient psychiatric hospitalization, and our outpatient DBT program,” says Dr. O’Brien. “We also found that we needed programs that provided more intensive support, not just to the teens but also to their parents and guardians.”

The multi-family skills groups are essential to the success of the program. “We recognize that if you’re working with teens that are experiencing high risk behaviors, the caregivers need support as well,” Dr. O’Brien says. “The whole family system gets impacted. By teaching and learning the skills as a family, they get a shared language they can use.”

Addressing an Unmet Need for Intensive Outpatient Care

To address that need, NewYork-Presbyterian/Columbia launched the Intensive Adolescent & Family DBT (IAF-DBT) Program at the end of 2022 to provide greater support to struggling teens and their families. It is one of a few intensive DBT programs in the area that serve as a bridge between inpatient residential treatment and traditional outpatient treatment.

Dr. O’Brien notes that while most individuals are accepted into the program following an evaluation, it is not suited for individuals with moderate-to-severe neurodevelopmental disorders or autism spectrum disorders. Additionally, those with primary substance use disorders or primary eating disorders may not be a good fit for IAF-DBT. “We have had a number of referrals that have been using our program to step down,” she says. “Once they get some stabilization in substance use or eating disorders, then they use our program to focus more on the emotion dysregulation that comes naturally with that.”

The IAF-DBT Program builds off Columbia’s outpatient DBT model, but it differs because it offers a multi-level step down approach built into the program design. IAF-DBT starts with a short 8-week intensive phase that offers more support than traditional DBT, including a parent group and a teen group that meets twice a week, but still includes a Multi-Family Skills Group. After the 8 weeks, families step-down to just the Multi-Family Skills Group as a component of traditional DBT outpatient treatment or other forms of outpatient care. This allows families to get more intensive support at the beginning of the program, but without having to extend or repeat the Multi-Family Skills Group once they step down to traditional outpatient treatment.

Columbia’s IAF-DBT program offers a teen group that meets twice a week in addition to Multi-Family Skills Groups, and a parent group.

“We needed a program that provided more intensive support to the teens and their parents and guardians,” says Dr. O’Brien. “We found that community, peer-to-peer support can be really beneficial in helping teens jumpstart and get more grounded and stabilized in learning the DBT skills and applying them as well.”

The IAF-DBT program also considers the busy schedules that teens and their families often have. “Our program is after school intentionally because we don’t want to get in the way of the school day,” says Dr. O’Brien. “We really want to get them back into their day-to-day life activities.”

Since launching, the IAF-DBT program has had steady enrollment, with an uptick when it began in December and another one in the spring. Dr. O’Brien estimates that around 80% of teens and families that have enrolled in IAF-DBT have completed the intensive phase, and future research is planned to show the impact the program has on the teens and families enrolled.