“The numbers are stark,” said Daniel P. Dickstein, MD, FAAP, chief of the Nancy and Richard Simches Division of Child and Adolescent Psychiatry at McLean Hospital.
In 2021, suicide was the second highest cause of death for young people 10-24 years of age, Dickstein said, citing data from the Centers for Disease Control and Prevention. One in 10 teenagers made a suicide attempt. The risk is higher for girls than boys and higher for Black teenagers than white ones.
The numbers spike further when it comes to adolescents who are LGBTQ+ or non-gender conforming, with more than 50% of LGBTQ+ youth seriously considering suicide and more than 20% of LGBTQ+ teenagers making a suicide attempt.
Over the past 16 years, McLean Hospital’s 3East residential programs have helped more than 1,200 adolescents—almost all of whom have attempted suicide—learn to cope with their own experiences, emotions, behaviors, and with the world.
The programs use dialectical behavior therapy (DBT) and other therapies to support teens struggling with thoughts of suicide, self-injury, eating disorders, relationship issues, trauma, as well as life experiences and conditions that impact their mental health.
Helping Teens Manage Their Mental Health
“Most of our residential patients have attempted suicide, many more than once. The common denominator for all our patients is serious difficulties regulating emotions, which leads them to engage in dangerous behaviors or otherwise profoundly affects their functioning,” said Judith Mintz, PhD, director of Clinical Services for the 3East Residential Program.
“These are adolescents whose emotions and behaviors impact their ability to have normal relationships, attend school, and lead healthy teen lives.”
Mintz started with the program soon after it began in 2007. What started as a girls-only residential program led to the development of other programs, including a boys’ residential program.
Some adolescents came into the 3East programs as gender nonconforming or gender fluid. McLean’s clinicians have always been comfortable working with adolescents and their families to find the best fit for any single person depending on their gender identity and specific needs.
Sometimes, situations concerning gender were clear-cut. A child assigned at birth as a boy wanted the girls’ program, and the family wanted the same. Sometimes, it got more complicated, such as when the family of a boy assigned as female at birth wanted the girls’ program because they thought their son was not yet comfortable with other boys.
Over time, more societal acceptance of transgender youth meant that more patients were coming into the program with gender awareness. For some, this meant recognizing gender dysphoria or other gender issues. For others, it meant supporting their peers.
This year, program leadership decided to integrate the girls’ and boys’ residential treatment programs. Instead of being organized by gender, the program is now organized according to DBT training level.
“It’s the right time for this change. Even patients who are completely comfortable with their gender identity sometimes want a nongendered program,” Mintz said, recounting the words of one resident: “I don’t want a binary gender program, no matter how I identify.”
Two Levels of Curriculum: Intensive and Advanced
McLean’s 3East Residential Program is now organized by the two levels of the DBT curriculum and the acquisition of DBT skills: intensive and advanced. In both sections, the treatments are tailored to each patient’s specific needs.
Sophia L. Maurasse, MD, medical director of the 3East Residential Program, highlighted the approach with these questions: “How do we create someplace for this person to learn this set of skills and put them back into the world in a way that makes sense for them, and puts them on the path that they’ve always wanted to be on?”
3East attracts adolescents who are vibrant, smart, funny, ambitious, and talented. They also often have diagnoses such as borderline personality disorder (BPD), depression, anxiety, post-traumatic stress disorder (PTSD), eating disorders, and obsessive compulsive disorder (OCD). The severity of their conditions means that the intensive part of the program includes a lot of monitoring and checking in.
In this curriculum, typically four weeks long, teens are just beginning to learn DBT skills, both in individual therapy and in group settings.
The move from the intensive to the advanced curriculum is a milestone achievement. Clinicians, patients, and staff have a goodbye ritual where people share memories, and patients might highlight what they have learned about themselves or what skills they have found particularly helpful, said Sara Land, PhD, program director at the 3East Residential Program.
“Moving from the intensive to the advanced curriculum reflects how much the patient has worked to acquire and apply new skills. There is less monitoring and more freedom in the advanced portion of the program, but also higher expectations,” explained Maurasse.
In the advanced section, the adolescents begin to apply the DBT skills they have acquired in different, sometimes triggering, environments.
One patient might need to sit with a tutor to experience exposure therapy to taking a math test. Another might work closely with a therapist to develop a plan for working or volunteering for the summer, while another might go home on a pass to test their DBT skills in real life.
“All of this is tailored to help the student prepare for that next step, based on their individual needs,” said Maurasse.
3East: Adolescent DBT Treatment Program
Learn how the 3East continuum of care supports adolescents using cutting-edge therapies like dialectical behavior therapy (DBT).
Closer to the Real World Environment: The Experience of the Day Program
The 3East continuum of care also includes a day program that was modeled after the original girls-only residential program. This level of care is also referred to as a partial hospital program.
Like the attendees of the residential program, the partial hospital patients have typically engaged in high-risk impulsive behaviors, including substance use, driving too fast, excessive spending, connecting to people online in unsafe ways, extreme gambling, or other dangerous activities. The difference is in the severity of the behaviors. Teens in the day program do not need to be monitored as closely as those in the residential program.
Peggy Worden, PsyD, program and clinical director of the 3East Partial Hospital Program, has experience with the benefits of a nonbinary program because the day program has always been coed. There are benefits to this structure, she said.
“Much of our work is done in groups, and patients get the benefit of interacting and applying their DBT skills with other adolescents who might not be like them. A cisgender female might get input from a cisgender male or from a trans perspective,” said Worden.
“That’s part of the treatment. They’re learning together. The skills are being developed naturally in a more typical environment. It’s more like the real world that these students will be returning to.”
Driving Program Evolution and Success for Patients
Both the residential and non-residential programs draw adolescents from across the country and around the world.
For example, students in one group might include individuals from Maryland, Arizona, Pennsylvania, and Colorado, as well as Lexington and Weymouth in Massachusetts. Internationally, the programs often draw teens from as far away as Puerto Rico, Costa Rica, Japan, and India.
Dickstein notes that there is some data showing that it is not gender identity that puts an adolescent at risk, but their environment.
If their families are supportive and they are not getting bullied at school or elsewhere, gender identity might not be a critical topic. In other cases, gender issues are paramount. Gender dysphoria can be the underlying cause of a suicide attempt, or it can be a contributing factor.
Across the board, though, “gender-affirming care is associated with a decreased risk of suicide,” Dickstein said.
“By evolving into a more gender-diverse program, we are meeting the needs of these young people. The program changes allow us to help more families and people who are struggling.”
He credits the dedication of 3East’s clinicians and staff for driving the evolution and progress of the work, including the change to become structurally nonbinary.
Maurasse echoed this statement but from a different perspective. She started at McLean Hospital as a trainee and has stayed, she said, because of the commitment she sees every day with everyone who works with these adolescents.
More than anything, she said, “3East is a place that remains committed to tackling very, very difficult cases. My colleagues are people with deep clinical experience working in a challenging field but with a lot of compassion and a willingness to be flexible. When we accept a patient, they become part of us.”
And that feeling seems to be reciprocated. Recently, one director got an email from a former patient about to go to college orientation who said that they wouldn’t be going to college if they hadn’t been treated at the McLean program.
Another former patient who has stayed in touch went on to get a PhD with a focus on suicidality.
Another 3East program participant still in contact, who was gender nonconforming and had both BPD and obsessive compulsive disorder (OCD), went on to get an MD/PhD degree.
To talk to the 3East admission staff about intensive mental health treatment for a teen who is struggling, call us today at 617.855.2820.
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