View episode transcript

Featured Guest 

Alejandra Arango, Ph.D.

Objectives

• Define Cognitive Behavioral Therapy (CBT) and Dialectical Behavioral Therapy (DBT).
• Define how CBT and/or DBT can help with depression.
• Define when each type of therapy is indicated.

Resources

• Dialectical behavior therapy for nonsuicidal self-injury and depression among adolescents: preliminary meta-analytic evidence (Child and Adolescent Mental Health)
• Combined treatment with cognitive-behavioural therapy in adolescent depression: meta-analysis (British Journal of Psychiatry)
• Mental health strategies to the school setting (TRAILS)

Disclosures

Alejandra Arango, Ph.D. has disclosed a relevant financial relationship with: Vita Health - Consultant/Advisory Role, Other - Teaching, Conflict is relevant but is managed.

This relationship is relevant, this company does work in the topic area. but the relationship ended on 10/31/23.

CME

Credits available: 0.5 

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Transcript

Syma Khan:

Hello and welcome to Breaking Down Mental Health with myself, social worker, Syma Khan, child and adolescent psychiatrist, Dr. Heidi Burns, and nurse practitioner, Dr. Christina Cwynar. Dr. Burns could unfortunately not join us today.

We are very excited to welcome back Dr. Alejandra Arango to our discussion about depression and therapeutic interventions, particularly cognitive behavioral therapy and dialectical behavior therapy. Dr. Arango is a licensed clinical and child psychologist and clinical associate professor at Michigan Medicine. Clinically, she's interested in working with adolescents presenting with depression, anxiety, psychosis and trauma, and for whom suicide specific interventions are a core aspect of treatment. Dr. Arango is involved in the interdisciplinary training and is a member of the Youth Depression and Suicide Profession Research Program.

Dr. Arango, let's start by discussing why therapy in general is an important aspect for treatment of depression, if medication is being utilized or not.

Dr. Alejandra Arango:

Thank you so much for having me back. It's really wonderful to be here and I think this is an important place to start. So, when someone's presenting with a mental health concern, be it depression, anxiety or anything else really, there are many points of intervention, and like you shared, medication is one of them. And regardless of that, therapy plays such a critical role in recovery. And there's many functions and there's many types of psychotherapies. One goal of therapy is really to help an individual better understand themselves, what their strengths are, what their challenges are. We saw sometimes call this part of intervention psychoeducation. Learning about why we think and feel and behave in certain ways can be really empowering and can sort of guide our response in different situations.

In addition to education, a really core component of therapy is skill building. And that's really crucial. And the idea here is that we don't know what we might face tomorrow, what things might sort of come up for us, whether it's related to depression or whether it's related to other life circumstances. And the better prepared we are to sort of face these challenges, it might be easier to overcome them and to continue to work towards our goals. In therapy you learn many different kinds of skills to manage many different kinds of symptoms that are present in depression. So, therapy really presents an opportunity for youth and families to learn a bit more about themselves and how depression looks for them and how it's impacting them across areas of functioning and empower them to use these tools to face the challenges that might come their way.

Syma Khan:

Thanks so much for that summary. I think there's a lot of ways that therapy can be beneficial. And a lot of people assume it's just like you go there and you just talk for an hour. But really, I appreciate the discussion of skills and learning strategies to be able to manage your symptoms and to feel better in control of depression or anxiety or whatever you're experiencing in that situation. So, one really common therapy technique that's shown to be evidence-based is cognitive behavior therapy or CBT. Are you able to share a little bit about CBT with us?

Dr. Alejandra Arango:

Yes, of course. So, CBT is a great example of an intervention that focuses on those two components, the education as well as the skill building component. And a course of CBT for depression often begins with education about depression. What does depression look like? How can it look differently across different people? How does depression impact our functioning across our different life domains and tasks? For kids, how does it impact their sleep or how they're doing in school or how they interact with their family members and peers? So, it starts with a lot of really rich education, as well as education that we call effective education, which is about our feelings. How do we identify when we're feeling a certain way, how do we know the body cues that might sort of indicate that we're having a certain emotional experience? Learning a bit about what the function and purpose of feelings are.

So, after there's been some comprehensive education about depression specifically and about emotions, CBT really moves to, like I shared, a skill building component. And CBT is really grounded in this understanding that our emotions and our thoughts and our behaviors influence one another. And that's a really core aspect of treatment and sort of this interaction between our thinking and our emotions and our behaviors we call the CBT model or the triangle. An example to showcase the way that depression might influence the way that a youth thinks might be something like, and this is quite over simplified here, but it might be something like a youth is in a situation and they might think life is never going to get better or, "I'm always going to feel like this." And this type of thinking may affect the way that the youth feels, right? They might feel hopeless, they might feel helpless, they might feel sad.

And when we feel hopeless and helpless and sad, it is really difficult to do the things that we need to do in our lives. And this may lead to withdraw and in turn, withdraw may lead to feeling even lonelier because we're not talking to anybody around us. And then that might lead to more hopelessness and even more difficulties with motivation. And that's just sort of an example of some of these cycles that happen sometimes where our thinking and our emotions sort of interact with our behaviors in ways that aren't helpful and that make us feel really, really stuck sometimes. And a big goal of CBT is to help a youth kind of break down some of these cycles and find, "Where are some points of intervention here?" And this is done through different ways, but one of the skills that is used to address the cycle or the point of intervention to address the cycle is really teaching youth about their thoughts and how their thoughts affect them and what they can do with them.

So, once we're able to identify thinking that may not be helpful to us, we can create some space between us and our thoughts. So essentially teaching a youth that just because we have a thought like, "This is never going to get better", does not necessarily mean that that is true. So, if the thought, "I'll always feel like this", pops into my head, we want to teach you to challenge that thought and to challenge the natural tendency that we have to just believe the things that come into our head. Kind of this idea that a thought is just a thought. And that any meaning that we add to it, we kind of have some control over that. And we can also teach youth to challenge thinking and replace these thoughts with thoughts that might be more helpful. And we sometimes call these coping thoughts.

So, for example, if I have the thought, "I will always feel like this or things will always be this bad". I might look at the evidence around and maybe sort of realize like, "Oh, yesterday I had a little bit of an okay morning. And I have this thing that I might be looking forward to." So, when we take a step back and kind of take all the evidence, it can be helpful in dispelling these thoughts and maybe coming up with another thought that might feel a little bit better. And it doesn't have to be the most optimistic thought, it might just be a realistic thought like, "Things are really, really hard right now and I'm looking forward to the weekend. Or things are really, really hard right now and I'm working in therapy to make them better." And when we land at these replacement thoughts or coping thoughts, we might feel a little bit different.

One thing I'll note about the skill which we call cognitive restructuring, identifying when our thinking is not helpful, challenging it, coming up with a coping thought is that is really hard. So, I can talk about it right now and it feels very obvious and it's really, really challenging. So, this is something that takes youth especially a bit of time to really understand, a bit of time to be able to practice and then even a little bit more time to be able to use it in real time in the moment. But it can be quite effective and for many youth it can be quite meaningful.

So that's sort of the cognitive component of cognitive behavioral therapy. But another key component is something that we call behavioral activation. So, when somebody feels depressed, like we talked about before, they might feel less motivated to engage in their life and do the things that are meaningful to them that they want to do that they used to have fun doing. And this in turn further impacts somebody's mood. So, in essence, somebody's feeling sad and unmotivated, they withdraw so then they feel more sad and unmotivated and probably withdraw even more. And we call this sometimes the cycle of inactivity. And that's really challenging to get out of. It's really challenging in treatment to tell a teen who feels zero motivated, who feels zero enjoyment that part of the solution is to do something.

But that's what behavioral activation is, right? It's essentially activity planning, sort of spending some time with a teen thinking about the things that they used to enjoy or things that they might be interested in exploring. And very slowly starting to plan activities so that they can get out of the space that they're in, whether it is they're spending all their time at home or even all their time in the room or even all their time in bed. And behavioral activation often starts really slow. So, for some kids, behavioral activation has been sitting in the living room for 10 minutes each day this week. And then we sort of build our way up from there to doing things that are more physical and that are more active with the idea that the more that we engage with our lives, the more opportunities we have to feel different. And that might give us a little bit more motivation and sort of energy to continue to do so.

A big part of CBT is keeping track of things and logging things. And so, if we plan a behavioral activation activity of taking a walk with your dog for five minutes every day, we often might have an adolescent jot down how they felt before and how they felt after to really make these clear links between the activities that we decide to engage in and the way that we feel after we engage in those. So that was a summary rate of two main components of CBT, the behavioral activation piece, the cognitive restructuring piece. And then there's many other skills that we often tack on, skills such as relaxation, learning about our bodies and when we might need to slow our bodies down and how that might be beneficial. Learning skills for problem solving, mindfulness, how can we be better at being in the present moment and accepting what is around us.

Dr. Christina Cwynar:

I think you did a very beautiful job of describing cognitive behavioral therapy. And this is often a discussion that we have with our families as we're recommending this type of therapy and referring them out to providers like yourself. But they often have this misconception of what therapy is. They have this Hollywood, "I'm going to go lay on a couch and put my feet up and now I have to spill my deepest darkest secrets and the therapist is going to maybe tell me how to solve all my problems." Youth often don't want to be told what to do. They don't want to talk about their partner or their significant other or the girls at school picking on them or whatever else is going on.

But this is very different. It is a skill-based therapy. And sometimes just reviewing that with patients and families, they're like, "Oh, okay, I like that. I want to learn how to fix my thoughts and reshape them and all these things and conquer this X, Y or Z that I'm experiencing." So, it's very different than what they think or what they're imagining therapies like. So, it often helps get that buy-in for therapy when you can explain what cognitive behavioral therapy is and why you're recommending that type of therapy. So, thank you for that beautiful description. So how has CBT, cognitive behavioral therapy, been shown to help children and adolescents with depression?

Dr. Alejandra Arango:

Yes. So, CBT is an evidence-based practice for the treatment of actually a range of concerns but also including depression. And what we mean by evidence-based practice is that we've done research that essentially says that doing a course of CBT, and that can be defined differently, maybe 12 to 16 sessions sometimes, is better than not doing anything at all and is sometimes better than doing other interventions. And in a recent meta-analysis that I was reviewing, which included 31 trials where CBT was used to treat adolescent depression specifically, the results indicated reductions in depression symptoms at follow-up. And so, there's been many studies sort of like that indicating that this approach can be helpful.

I think one thing to note, and this is true for a lot of the mental health literature and especially for intervention work, is that we have a lot more to learn about how specifically this is helpful, what component of CBT is the most helpful, is the most crucial, what is the appropriate dose? For a long time, we've kind of structured treatment as being one time a week that somebody comes in for one hour and I think we're still learning is that the best way? What about two times a week? What about an hour and a half? Learning a little bit more about the dose, like I said, what parts of cognitive behavioral therapy are effective? The behavioral activation, is that on its own enough? Is it the combination with the cognitive restructuring?

And I think even further, learning about how this might be different from youth to youth with different presentations. So, we're talking about adolescent depression, but one thing that we know about adolescent depression is that it's often comorbid with many other things. So, I work in the depression clinic in outpatient psychiatry here, and so I do depression intake evaluations. I very rarely get a team that only meets criteria for depression. There is anxiety, there might be a trauma history, there might be other dynamics at play. And our research isn't there yet to consider all of those components. So, we know that it's helpful, that it is promising we have the strongest evidence for CBT as far as treating depression and we have some to learn still.

Syma Khan:

I think it's helpful to remember that CBT may look different for different youth too. And I think that's an important reflection that I think sometimes you do go to a clinic where they're really delivering that structured 12-to-16-week intervention and for other youth it may be integrating aspects of CBT into other types of therapy. So, I think really that emphasis that we may need to study more and really recognize that mental health interventions need to be tailored to the youth and specifically what's going on, if they have a trauma history, how are we going to integrate that into treatment? And so, I think it's really important to remember that. And I think when talking to families and maybe they've tried CBT, maybe it wasn't just delivered the right way. Si kind of recognizing that sometimes we maybe just try it in a different model with a different therapist, that there can be a lot of modifications. And I think we're still learning, but we know it is evidence-based and we know it is effective. It's just figuring out what the right formula is for that.

Dr. Christina Cwynar:

So, switching gears a little bit, let's talk about another form of therapy. Can you tell us a little bit about dialectical behavioral therapy or DBT?

Dr. Alejandra Arango:

Yes. So DBT is another evidence-based intervention. And this was developed by Dr. Marsha Linehan initially for the treatment of borderline personality disorders in adults. And over the past couple decades, the intervention has sort of been tailored for use in adolescents. So, at the start, the idea behind DBT was to have an intervention for individuals who perhaps were impulsive or engaging in impulsive behaviors or self-destructive or self-harm behaviors. And like I shared, there's been an adaptation which we sometimes call DBTA of really thinking about this DBT model for use with adolescent patients. And the structure of DBT is a little bit different compared to CBT.

I think most typically we see CBT being delivered in this weekly outpatient therapy format. And the structure of a comprehensive DBT program is a little bit different because it includes several components. So, it does include a weekly individual therapy portion, but it also includes participation in a skills group that also meets weekly. Access to coaching, which is sort of real time connection with a provider to help you deploy the skills that you've been taught. And comprehensive and adherent DBT programs also have what they call a consultation team, which is for the providers that are working with the patients to have a space to discuss what's happening with the patients. It also adds this component of adherence.

The first word in DBT is dialectical. The idea behind dialectical is there's many ways to sort of see a situation and we all have different sort of viewpoints and ways that we get to those viewpoints. We all have life experiences that might make it so we see things in a certain way. And we often in life encounter these moments where two things that appear or actually are opposite can be true at the same time. And learning that is really powerful. And many skills in DBT, which focus on acceptance and perspective taking can help us get to that place. And an example of that is this idea that I'm doing the best I can and I also could be doing better. So those are two things that may seem opposite initially, but with some acceptance and looking at them from different perspectives, we can hold true at the same time.

So, I'll talk a little bit about the individual therapy component of DBT, which is structured in this progressive way that begins by really addressing safety concerns. So, like I shared at the start, many of the individuals that are referred to DBT might have a self-harm history. And so, we really start by establishing safety and doing safety planning and helping to understand what are the functions of these behaviors for these youth and creating a treatment plan around that. And then it progresses to addressing behaviors maybe that are interfering with treatment and ultimately working towards supporting a patient as they improve their quality of life in whatever way they define that and work to meet their goals.

So that was the individual component or the individual therapy component of DBT. But there's also, like I shared, the skills building group that youth attend, which is really wonderful and kind of focuses on these four different domains with the first domain being mindfulness. So, youth are taught a lot of skills in the areas of observing and describing and engaging in the present moment while being aware and being intentional, working really hard to not judge or make attempts to sort of alter experiences. So how can we sit with what's around us and kind just accept that it is and describe it and be able to see it without any judgment? So those are the mindfulness skills.

Youth are also taught distress tolerance skills, which equipped them with tools for controlling their impulses and accepting unchangeable circumstances and tolerating painful experiences. Because we know that when we experience pain or distress, we might be more likely to act impulsively and that interferes with our goals ultimately and the things that we want to meet. So, distress tolerance skills really teach us to identify these moments and act in ways that are in alignment with whatever goals we have.

We also have emotion regulation skills that are taught that really help youth identify and describe their emotions, understand the purpose of emotions, "Why do we have feelings and what do they do for us? What are they trying to tell us?" Help us understand the impact of emotions and also how do we increase positive emotions? There's an overlap here with CBT, in many places actually, but here we can increase positive emotions by engaging in positive activities or by taking care of ourselves through our sleep or the ways that we eat. So some more comprehensive self-care components come in here too.

And the last skillset, let's say, that is taught in the DBT skills group is interpersonal effectiveness. And the idea behind interpersonal effectiveness is to build skills to navigate interpersonal challenges and to maintain relationships, positive relationships. It gives youth skills to be a bit objective and help them to set boundaries and ask for what they need and do all those things and feel good about the way that they did the. And so, all of those skills, like I said, are taught in the skills group and then are applied and reinforced an individual therapy. And all of those different components together make DBT. And that was I think a really brief sort of summary of what goes into DBT. Many DBT programs, youth are in them for months or even a year. So, a lot, a lot is covered and things are repeated and reinforced, but that's a general idea.

Syma Khan:

I think that was an excellent summary of a therapy that I think is pretty intensive. And so, it's nice to hear those core aspects of it for providers to be able to take back and think through when they're working with an adolescent. And oftentimes there's also a family component. And I think we could probably touch a little bit maybe about the family component within CBT and DBT.

Dr. Alejandra Arango:

Yes, absolutely. Yeah, when we work with youth, families are incredibly important. So, if we think about, for example, CBT, there might be different ways that a caregiver or a family might be involved. I always involve families in the education piece, for example, helping them understand their teen's behavior in the context of depression. We know one of the symptoms of depression in adolescents and youth that is often present is irritability. So, helping a parent understand why their kid might be behaving in a certain way and a way that might be different to how they behaved before. And also giving families skills to support both the use of the skills that the teen is learning.

So, teaching families about behavioral activation and how can they support that. Maybe it is that the kid has a really hard time walking the dog 10 minutes a day, but if it's with dad then it feels a little bit better. If it's with their older sister, then it feels like there's a little bit of accountability. Like I shared earlier, the cognitive restructuring piece can be really challenging and we often have youth and families do a lot of logging and keeping track of things. At the end of the day you faced a hard situation, identify a thought that was unhelpful and kind of work through the process of challenging that thought. And for some youth, having a caregiver involved in that process might be helpful and for others not. I think, like we were talking about earlier, sometimes teens have a hard time being told what to do. And so, for me as a clinician it's incredibly important to figure out with them how they think their family might be involved and what they would find helpful and kind of problem solve if things don't go just the right way.

And I know in DBT, families are often involved, sometimes there's multifamily groups where they come in and the youth and their caregiver or family member, they're all learning these skills. I think what's really cool about these interventions is that these skills are for everyone really. Sure, they're helpful when we're facing certain challenges, but throughout the day we all need to challenge the way that our brain might be kind of making us see a situation or we might need to tolerate a distressing situation or we might have to be in the moment and accept something. So, I think the more people in the youth's world that know these skills and are able to apply them themselves and sort of encourage the youth's application of them, I think the better.

Syma Khan:

I think so often parents feel lost in how to support their adolescents. So, I think that that aspect can be really helpful that they kind of are understanding. And I think broaching it within confidentiality, that you are still maintaining the youth's confidentiality and what they share is still private, but that there's ways that we can integrate their family with their consent and their agreement. Because we know that oftentimes we need to work with the family unit to help the adolescent. So just jumping back, we talked a little bit about some of the evidence around CBT, would you like to just share with us how does DBT help children and adolescents with depression?

Dr. Alejandra Arango:

Yeah, so much of the work using DBT has examined the impact of DBT in decreasing self-harm behavior, suicide attempts and suicidal thinking and teens with promising outcomes. I was taking a look at a somewhat recent meta-analysis by Cooke and colleagues, they found preliminary evidence regarding the effectiveness of DBT interventions in the treatment of non-suicidal self-injury and depression in adolescents, though for depression that the effect sizes were small, which is unfortunately not uncommon.

Dr. Christina Cwynar:

Okay, so we've kind of reviewed cognitive behavioral therapy and dialectical behavioral therapy, but how do you determine where to refer a patient?

Dr. Alejandra Arango:

I think that's an excellent question and I think it's on a case-by-case basis, like most of the clinical decisions that we make. CBT is often the first intervention used and where most youth end up being referred. I do think that in the presence of self-harm or elevated suicide risks where there's a really notable component of interpersonal difficulties, DBT might be indicated for any youth where we're concerned that there might be some borderline personality disorder features or traits, DBT might be indicated. I think an important thing to think about here is access and what we have access to and it can often be hard to get youth into comprehensive DBT programs. And there's quite a commitment that is involved. So, I think like all decisions, we want to decide this with the family, what they have access to, what feels feasible to them, what feels like an acceptable next step, what they may be able to commit to time and effort wise, might be other components that we think about.

And there's sort of DBT-informed interventions that are out there too. So, in our department we have a DBT skills group that is sort of seen as an add-on intervention. So, I have many kids that I see where I'm providing CBT for depression or other things where some of these skills might be helpful, especially like the multifamily groups, like you were saying earlier, where it would be really helpful for everybody in the family to gain some of these skills. So, we may be doing CBT individually and they might be learning some of these DBT skills in that group setting. I wish I had a clear answer, but it sort of depends, but those are some things to consider.

Dr. Christina Cwynar:

No, I think it's really helpful. And as we know, resources can be really scarce and sometimes the situation may not be clear. We may be thinking, "Oh either may be helpful, let's get on both wait lists and see what opens up first. Give it a try. If it's really helpful, go down that avenue first. If this one opens up first, let's give this a try first." And go down that avenue. And just reminding patients and families that not one thing fits all people. So, we may have to do an adjustment down the line. And that may be the type of therapy, but it may be the provider, it may be the location, it may be the frequency, the dosage, whatever it may be, those things may change. And we kind of alluded to this earlier, but do you have any recommendations on how we combat the stigma against therapy?

Dr. Alejandra Arango:

Yeah, this is a hard one, an important one. And I think my mind goes to education and awareness, even what we're doing here today, right? Helping people learn a bit more about what treatment does look like and sort of dispelling some of these misconceptions about mental health challenges in treatment. And I think normalizing things from a young age is really important. And so, something that's been really cool to see is that many school systems have incorporated social emotional curriculums, even some that are CBT based, like the TRAILS to Wellness program here in the state. And that is wonderful because like we said, many of these skills are helpful for many people regardless of depression. And if the use of these skills is normalized and some of these words are normalized from a young age, I think it's going to shape the way that our community kind of thinks about this over time.

As a provider, for me, it's really important to involve as many people as I can in the youth's treatment team. So even if I am delivering individual outpatient therapy, I think about us as a team. So, there's the youth and then there's maybe the parent that's bringing them and then thinking about what are the other caregivers that might benefit from some of this education. Again, with the goal of normalizing that many teens struggle with depression unfortunately, and educating the family system as much as we can about the things that we can do that could be helpful.

Dr. Christina Cwynar:

Yeah, I always like to empower the parents to also include those other care providers because these youth aren't with them 24/7, so the teacher needs to know what you're working on to a degree. Like, "They're having panic attacks, this is how we're approaching those panic attacks. Or this is how we're addressing X, Y, or Z." So, then they can redirect the youth to do whatever you are working on in that moment. And they don't need to know everything obviously, but they do need to be keyed into some of these elements so that they can help this kid on their path to wellness as well.

Dr. Alejandra Arango:

Yeah, that's exactly true. I know we focus on these interventions that maybe happen with a specific provider in a therapy setting. But I think, like you're saying, we all have a role whether it is the teacher or a kid's coach or a religious leader in their organization, everybody has a role. And the more that we can kind of help the teen know that they have many sorts of places to turn to that understand, I agree that that can be incredibly beneficial and powerful.

Syma Khan:

And I think approaching it in non-mental health settings too can really help normalize and promote engagement. I don't think we need to see someone just with severe depression that needs to access CBT, right? These skills can be really helpful with someone that maybe has mild to moderate symptoms and if we intervene early, we may prevent them from having more of those severe symptoms that really impact their functioning. So, it can be really helpful when families are in their pediatrician's office when there's maybe a conversation about what CBT or DBT is because that helps them have that trust with you and that you're someone that is making a recommendation that they hopefully will follow up on then because there's a relationship there and that you are normalizing that intervention that could be really helpful for their teenager. So, Dr. Arango, any other thoughts with us before we end today?

Dr. Alejandra Arango:

Well, thank you so much. It's been nice to talk to both of you about this. I don't know, for me in summary, it's exactly what we were just saying, right/ That this is everybody's business, whether it is knowing what intervention is helpful or listening to a teen or just directing them to a place that could be beneficial for them when they're struggling with these things. And like Syma was saying earlier or later, there's so many points that we have of intervention. And yeah, we primarily talked about therapy, but there's other sort of programs that are helpful for teens and helping them feel a sense of community and a sense of engagement that can ultimately hopefully reduce some of those symptoms.

And I think that the last piece, and I know I highlighted this before, is that we have a lot to learn and we also have a lot to learn about. Unfortunately, a lot of the research that is done is in a certain population, a lot of the research we have on depression and suicide risk ends up being in white populations and with biological female youth. And so, I think we still have a lot to learn about how all these things apply across different people with different life experiences. But I think what's promising is that much more of that work is being done.

Dr. Christina Cwynar:

And I think it's great that schools are starting to integrate these skills at even younger ages, but families can do that as well. So, pediatricians can even start directing families towards some of those resources. There's some great even decks of cards or even board books that walk even your toddler through how to use mindfulness skills or deep breathing. And these are things that we can start integrating into our well-child visits or have in the waiting room or our ERs or families can be doing at home from the day they're born.

Dr. Alejandra Arango:

That's right.

Dr. Christina Cwynar:

So Syma, any thoughts from you?

Syma Khan:

Yeah, I think I just really love that idea of starting early and really building our emotional language. And I think we're seeing it more with the youth that are way more open and way more talking about their feelings saying, "I'd like to go to therapy." So, I'm glad I'm seeing that movement and hopefully we continue that.

Dr. Christina Cwynar:

Well, thank you for joining us today and sharing your expertise. We appreciate all your time and dedication to this project. Thank you to everybody that tuned in this week. Nurses, social workers and physicians can claim CMEs and CUs at uofmhealth.org/breakingdownmentalhealth. You're able to do this anytime within three years of the initial air date. We hope you'll join us next time.