Working with teens in private practice can be challenging. Working with teens who are self-harming, suicidal, emotionally dysregulated, or cycling in and out of higher levels of care adds another layer of complexity.
Many therapists understandably feel anxious when a high-risk teen walks into the office. There are safety concerns, liability questions, worried parents, and often a teenager who has already been through multiple therapists or hospitalizations.
So how do we create therapy that feels both safe and effective?
Katie K. May has spent more than a decade working with high-risk teens and their families. Her approach combines structure, validation, caregiver involvement, proactive safety planning, and practical skills that teens can actually use outside the therapy room.
One of the most powerful ideas from our conversation was also one of the simplest:
“You don’t have to have hope, because I have a plan.”
Meet Katie K. May 
Katie K. May is a licensed therapist, author, speaker, trainer, and group practice owner whose mission is to stop the revolving door of hospitalizations for teen self-harm, suicidal behaviors, and shutdowns by giving families and clinicians practical tools that create lasting change.
She is the founder of Creative Healing, a multi-location teen support center in the Philadelphia area, and the author of the #1 Amazon best-seller You’re On Fire, It’s Fine: Effective Strategies for Parenting Teens with Self-Destructive Behaviors. Her second book, Teen DBT in Practice, provides clinicians with a practical framework for applying DBT with adolescents and moving beyond surface-level behavior management toward meaningful, lasting change.
One of a select few Linehan (“Lynn-a-hayn”) Board-Certified DBT Clinicians in Pennsylvania, Katie specializes in evidence-based treatment for self-harm, suicidal behaviors, and complex emotional challenges in teens. She is an ongoing guest expert on Good Day Philadelphia, where she shares practical guidance on teen and parent mental health.
Known for her clinical practicality and lived experience as a teen who once turned to self-harm herself, Katie bridges the gap between the therapy room and the family living room. Her work helps parents and professionals decode behavior as survival, regulate the nervous system, and create new coping strategies that last because the whole family is integrated into the treatment plan.
When Hope Feels Dangerous
For Katie K. May, effective work with high-risk teens begins with a combination of structure, validation, caregiver involvement, and a clear treatment plan. Many of the teens she works with have already tried therapy multiple times. Some have been through what feels like a revolving door of hospitalization and treatment. By the time they arrive in her office, hope may actually feel risky.
That is why one of the things Katie often tells teens is, “You don’t have to have hope, because I have a plan.”
Rather than expecting a teenager to arrive motivated, optimistic, and ready to open up, Katie believes therapists can provide clinical leadership from the beginning. She guides the session, explains what to expect, asks specific questions, and lets the teen know that therapy has direction. At the same time, she works to preserve the teen’s sense of agency. Even if a parent brought them to therapy, the teenager still deserves the opportunity to decide whether they trust the therapist and whether this feels like the right place for them.
Structure Can Help Create Safety
For some teens, a completely open-ended therapy session does not necessarily feel freeing. It can create more uncertainty, especially when the teen is already emotionally dysregulated or unsure of what to expect.
Having a therapist who confidently guides the process can help create a sense of safety. Structure gives the teen a clearer understanding of what is happening, why it matters, and where the work is going.
That structure does not mean taking away autonomy. Instead, the therapist can provide direction while still giving the teen a voice in the process.
Validation Is Important, But It Is Not the Whole Treatment
High-risk teens need to feel understood. They need someone who can genuinely recognize how difficult life feels without immediately jumping in to fix everything.
Getting out of bed, going to school, taking a shower, dealing with relationships, or simply making it through the day can feel enormous when emotions are intense.
A therapist can communicate, “I see how hard this is for you,” while still helping the client move toward change. The goal is not just to hold space for suffering. It is to understand where skills are breaking down and begin building the skills that can help the teen move forward.
Helping Teens Build a Life Worth Living
Katie describes the therapeutic process as looking at two sides of a river. On one side is where the teen is now, including what they are struggling with and how those struggles are showing up in everyday life. On the other side is the life they would like to have.
In DBT, this is often described as building a “life worth living.”
Therapy becomes the process of creating the stepping stones between those two places. Those stepping stones might include coping skills, emotional regulation strategies, mindfulness, changes in thinking patterns, or learning how to ask for support.
The goal is to give the teen something to move toward, not just something to move away from.
Parents Have a Role in the Process Too
The teen is not the only person involved in crossing that river.
When a teenager is struggling, parents understandably want to help. Sometimes that help can turn into micromanaging, repeatedly checking in, giving constant instructions, or trying to carry the teenager through the problem. Other parents may become highly anxious and unintentionally escalate alongside their child.
Katie uses the river metaphor with parents as well. The parent’s role is not to stand on the riverbank directing every step, and it is not to put the teenager on their back and carry them across.
Caregivers have their own work to do.
Caregivers Need Support Too
That work might mean learning how to validate their teen, identifying their own emotional triggers, responding differently during conflict, or recognizing when their own fears are influencing how they react.
This is why Katie includes caregiver-only intake sessions and ongoing caregiver touchpoints in treatment. Parents need a place to talk honestly about what has been difficult without the teen sitting in the room feeling like a burden.
It also gives the therapist an opportunity to understand what skills the caregiver may need to develop. Supporting the parent can ultimately help create a more supportive environment for the teen too.
Don’t Wait for the Next Crisis
When a teen has a history of self-harm or suicide attempts, Katie does not wait until another crisis happens to start looking for patterns.
She wants to understand when the behavior first happened, when it was most intense, what happened before previous attempts, and what common triggers were present. Maybe those triggers are relational. Maybe there are sensory needs that are not being met. Maybe there are predictable patterns in how the teenager and caregiver interact when emotions begin escalating.
The goal is to understand those patterns before the next crisis.
Looking backward can help therapists and families recognize what may happen next and create a plan before emotions become overwhelming.
Make Safety Planning Specific
Katie works with families to build proactive safety plans that identify what the teen looks like at different levels of emotional activation.
What does the teen look like when they are calm? What changes when they start becoming overwhelmed? What happens when they become completely flooded and may not even have the words to explain what they are feeling?
Just as importantly, the plan identifies how other people should respond at each stage.
Safety planning becomes much more useful when it does not simply list warning signs. It can also give caregivers clear guidance about what support actually looks like for that particular teen.
Sometimes Support Means Doing Less
Katie shared an example from her own experience as a parent. When her child became overwhelmed and covered their head with a blanket, her instinct was to immediately start asking questions. What is wrong? What do you need? How can I help?
Over time, she realized that more questions were not what her child needed in those moments.
Sometimes the better response was simply bringing them a drink, sitting beside them, and saying, “I’m here. If you want to talk, great. If not, I’ll just sit here with you.”
That distinction matters because support does not always look like talking. Sometimes a teenager who says, “Leave me alone,” actually does need space to regulate.
Following them into their room and continuing to ask questions may come from a place of love, but it can also unintentionally make the situation worse.
Behavior Is Communication
Another important part of Katie’s framework is looking at behavior as communication.
Instead of focusing only on how to stop a particular behavior, therapists can become curious about what the behavior is doing for the teen.
What need is underneath it? What emotion are they trying to regulate? What are they communicating through behavior that they may not yet know how to communicate another way?
Understanding the function of a behavior can help therapists move beyond simply trying to eliminate it and instead address what is happening underneath.
When Emotions Feel Like a Fire
For some emotionally sensitive teens, their internal experience can feel like a fire burning inside them.
When emotions become that intense, every decision can become an impulsive attempt to put the fire out. When someone feels like they are on fire, their first thought is not necessarily, “What is the healthiest long-term choice?” Their immediate thought is simply, “Make this stop.”
Understanding that can change the way therapists view impulsive behavior.
Treatment can help the teen recognize emotional escalation sooner and learn safer, more effective ways to respond before they reach the point where everything feels unbearable.
Give Therapy Sessions a Clear Structure
Katie also emphasizes the importance of structure within each therapy session.
Rather than relying entirely on asking the teen what they want to talk about that day, she uses tools such as diary cards and weekly tracking to understand what happened between sessions, what skills were practiced, what worked, what did not work, and what the highest-priority target should be.
This is especially important when working with high-risk clients. Without structure, a session can easily become focused on a conflict with a friend or frustration with a parent, only for the teenager to disclose suicidal ideation or a suicide attempt in the final few minutes.
A consistent session structure helps therapists identify and address the most serious concerns first.
Help Teens Use Skills Outside the Therapy Room
One of the common frustrations therapists have is that their clients may understand coping skills but still struggle to use them when emotions are high.
That is why Katie’s framework places such a strong emphasis on reviewing what happened during the week, identifying where skills broke down, and practicing how those skills can be applied differently next time.
The goal is not simply for the teen to understand a coping skill intellectually.
The goal is for them to be able to access it when they actually need it.
Therapists Need a Plan Too
High-risk clinical work does not only affect the teen and their family. It affects the therapist.
Working with suicidal and self-harming clients can create a tremendous amount of anxiety for clinicians. Therapists may worry about making the wrong decision, hospitalization, liability, or whether they are doing enough.
That anxiety can influence clinical judgment if therapists are not aware of it.
Katie believes therapist self-regulation and sustainability are essential parts of working effectively with high-risk teens. Having a clear framework, access to consultation, and objective ways to evaluate the work can help therapists feel more grounded.
Effective Therapy Does Not Always Mean a Happy Client
A therapist’s effectiveness cannot always be measured by whether a teenager walks out of the office feeling better.
A chronically depressed teen may still feel sad after an effective therapy session.
Instead, therapists can look at whether they addressed the highest-priority concern, used appropriate validation, provided direction when needed, helped the client practice skills, and followed a treatment structure that supports meaningful change.
Those markers can give therapists a more sustainable way to evaluate their work.
Connection and Clinical Leadership Can Coexist
Ultimately, the goal of therapy with high-risk teens is bigger than simply stopping a behavior.
It is helping teenagers build a life they actually want to participate in.
That takes connection and validation, but it also takes leadership, structure, skills, caregiver involvement, and proactive safety planning.
A teen may walk into therapy feeling like they have tried everything. Their parents may feel exhausted. The therapist may feel the weight of the work too.
Hope may not be available right away.
But sometimes hope does not have to come first.
Sometimes the first thing a teen needs is someone who understands what they are going through and has a plan for helping them move forward.
Gordon Brewer: Well, hello everyone, and welcome again to the podcast, and I'm, I'm really glad and excited for you to get to hear from Katie K.
May today. Katie, welcome
Katie K. May: Thanks, Gordon. I'm excited
Gordon Brewer: to be here. Glad- yeah, glad to have you back. A- and, um, we'll ha- we'll put in the show notes the other episode she did. I can't remember. We were just kind of thinking. It's, it's been a while, but, uh, anyway. It's been a long time. I
Katie K. May: was probably talking about groups at that point, yep.
Gordon Brewer: Yeah, probably so. Probably so. So but anyway, Katie, glad to have you. As I start with everyone tell folks a little bit more about yourself and how you've landed where you've landed.
Katie K. May: Absolutely. So I'm a licensed therapist in the state of Pennsylvania. I lead a team of other therapists, and we all specialists- specialize in doing high-risk work with teens and families, really with a passion to keep teens out of the hospital and in a life that they love.
And I came to this work through my own lived experience of being a teen who struggled, and then finding meaning in life through my life experiences, and then wanting to give back and shorten the struggle for others who have had experiences like mine.
Gordon Brewer: Yeah. Isn't that funny how most of us in this, in this space end up here because of our own stuff?
It's just really... Yeah, I n- that's true for me, but I mean, it's just yeah, it's really cool. You feel like
Katie K. May: you have to make meaning of things that were hard, right?
Gordon Brewer: Right, right. Like, for
Katie K. May: me at least, it's like why else would this have happened if not for me to then give back or do something with it?
Gordon Brewer: I know, um, K- Katie and I have crossed paths in different ways, and we've kind of lived these parallel existences- ... in this space. But I know, Katie, one of the things that you, um, are really passionate about, like you said is working with teens. And you've put together some, just some ideas and frameworks of how to help people with, um, you know, to put the clinical term on it, resistant teens or working with, you know kids that, um, you know, struggle and maybe don't want to be in therapy and that kind of thing.
So tell us what you've learned and what you, some of the key things.
Katie K. May: Absolutely. Yeah, so my specialty is working with high-risk teens, self-harming, and suicidal teens. And what I would say is that the majority of the clients that I've worked with or that come into my center have been to six to 10 other therapists, maybe have been in that revolving door of hospitalization.
And so the framework that I teach, it's in my book called Teen DBT in Practice, and I also teach it in a training program, is all about how to create, how to deliver structured therapy that also is connecting, is also accepting and validating. And I think if I were to pull back and give you the 30,000-foot view, and we can dig into whatever part of that makes sense- Mm-hmm
that is the crux of it, is being able to validate a teen's experience, being able to say in a really radically genuine way, "That really sucks. I can see how much you're struggling. I can see how hard it is- Mm-hmm ... to wake up every day and even engage in life, take a shower, go to school. Like, life is really hard for you."
And at the same time, not stay stuck in that place as a therapist of just validating- and holding space, but being able to support them in understanding where skills break down for them, and put skills in place that allow them to move forward and not stay stuck in that suffering.
Gordon Brewer: Right. Yeah, it's a it's having worked in...
I worked for a nonprofit that worked with at-risk ch- children and youth back in the day, and, um, it is really difficult to connect, and I think some people have, uh- Have a, a better talent for it than I really ever figured out how to do. But, um, yeah, so where, what do you find is the starting place with you, you know, thinking about, you know, a teen's coming in, maybe they've been forced to come to therapy, and they're just, like you said, their life sucks and they just don't see any hope and that sort of thing?
Katie K. May: Yeah. I love that you said that about not seeing hope, because that is the starting point for most teens and the most parents that bring the teens to therapy. I would say that for a lot of them, hope feels dangerous because they've had so much treatment that has not worked or that they haven't engaged fully in.
And so one of the lines I find myself saying a lot is that, "You don't have to have hope, because I have a plan." And that's, you know, them coming in and whether they're resistant, hesitant feeling very- Mm-hmm ... vulnerable, I present very much the same way as I'm talking to you, Gordon, as like confident. I tend to guide the session rather than h- open the space and say like, "So what brings you in?"
Because what I find is that when you have a teenager especially who is emotionally dysregulated, who has a lot of uncertainty, who doesn't know what to expect, who may have been asked to share their story 100 other times, what they need is someone to guide them through the process. What they need is clinical leadership, and so that's where the structure of therapy becomes so important.
So I'm saying- Mm-hmm ... to a teen, "Hey, I have a lot of questions for you today. My goal is to get to know you and get to know whether you're in the right place for me to support you, but your goal is also to get to know me and decide if you want to be here and if this is the right place for you." And so I think that, that puts some balance in that power dynamic when a lot of times a teen is brought to therapy by a parent.
A lot of times, though, they're not. They've suffered enough and they're tired of suffering, so they want to be there. Right. But also, we wanna be mindful of being adults in the room with a teenager who is not a child, is not an adult. They're somewhere in the middle, and we need to honor where they are and, and help them feel some agency in the process.
Gordon Brewer: All right. Right. It's kinda like, um, kinda like naming the elephant in the room, you know? Always. It's just kinda like, yeah, yeah, yeah. Yeah. A- a- and, and giving, giving that space. So yeah, so what, um, kinda guide us through kind of your framework, I guess that's a good way to put it, of- ... and your process and your plan and that sorta thing.
Katie K. May: Yeah. So it is a framework. It's, I would say it's a framework or it's principles more than it is a protocol. So it's not step one, two, three, four, five. It's these are the principles that make therapy really effective with high-risk teens and caregivers. So it starts with that intake session, where we're meeting with parent for parent and teen together.
We're also meeting with t- with teens separately, getting to know them, giving them, again, that sense of empowerment. And a next part of the process is that we also meet with caregivers for what I call the caregiver only intake, and this is really important to join with parents and allow them the space to express maybe how hard it has been for them to parent a teen who's- Mm-hmm
been struggling, without the teen present to hear that and feel like a burden. It also allows us to understand what the parent's skills deficits are, because if a teen is struggling, the parent might not know how to validate. The parent might escalate alongside the teen. And when I say parent, I mean any caregiver in the home.
Mm-hmm. Um, anyone who's caring for the child. And so it allows us to join with the caregiver and integrate them into the process. From there, we're understanding really clearly what are the presenting concerns. I'm very behaviorally specific, so I don't just wanna hear, "I'm depressed." I wanna know, what does that look like in your every day?
Mm-hmm. Are you having trouble getting out of bed? Are you... Is your depression an 8 out of 10? Are you having really self-critical thoughts? I'm digging in and understanding a very clear picture, and that brings us back to this high level view of I wanna understand what it's like to walk a million miles in your shoes and how hard it is for you before I ever jump in with a coping skill or tell you how to change this.
Gordon Brewer: Yeah. Yeah, so it takes a... I- i- how long does that... I would think that doesn't happen just immediately. It takes time- Correct ... to kinda build that rapport and that sorta thing. And so as you get that rapport- I guess one thing that is important is to elicit some kind of curiosity from the team.
Does that make sense? I mean, is that something that you've ever thought about? I mean, as far as, you know, like, "I've got some ideas about that. Are you interested in hearing them?" Kind of-
Katie K. May: Oh, more
Gordon Brewer: like- ... kind of thing. Yeah, yeah
Katie K. May: Yeah. Yeah, yeah. I would put that in the frame of, like, engage- like consent-based treatment almost.
Like, "Hey," like- ... well, so what I would do is have them, after we're looking at what are the concerns, I'm also looking at, well, what do you want, not just out of treatment, but out of life. We call it life worth living goals. Mm-hmm. So whether that's creating a collage or talking through it, or we have some- we have something called the life worth living domains, and we can go through these different areas.
And so once I have those two sides, then I'm doing more of what you're saying, Gordon, about, like activating that curiosity or, like opening that loop. So I'm saying, "Here's how you're suffering." I'm, if this is a podcast, one hand, in one hand, "Here's how you're suffering." Yeah. In the other hand- Yeah ... "Here's where you want to be, so let's look at that bridge in the middle.
Let's look at how to get there." Right. "Are you open to hearing my ideas about what it would look like to get you to the other side?" Right. So that's how I would be doing that.
Gordon Brewer: Yeah. So tell us more as far as, uh, the things that you g- find that really, I'm sure it's not 100%, but the things that work a lot and work well
Katie K. May: Yeah.
So there's a couple things that I would say. One is, well, I wanna go to we're talking about kind of bridging the gap between two sides. The way I present this to families is using something ca- I call the river metaphor, and what it does is it teaches everybody in the family what their role is in therapy.
So we're all on one side of the river looking at the other side of the river. Teen's job is to be willing to cross the river and being open to taking the steps across the river. My job with that teen is to build the stepping stones to help them cross the river. So that's when you're saying, like, "Well, what helps them get there?"
This is coping skills. This is interventions that we're working on in therapy to help them hold their big emotions or shift their thinking patterns or be mindful of what's happening for them without reacting. So these are all the things that we're working on in therapy and having them practice to build those stepping stones so they get across the river to their goals.
But an important piece in working with teens that I think gets missed is also what are the parents doing in the river metaphor and in this therapeutic process? Because if the parent is standing on the bank of the river watching their teen cross the river, they might be doing things like, "Step with your right foot, step with your left foot, step on your toes, step on your heels," micromanaging and wanting to be in control of the process.
They might be doing things like saying, "Don't fall in the water. It's cold. Watch out. There's an alligator," and being anxious. They might be putting the teen on their back and saying, "I'll just walk you across the river. I've done this before. I know how to do this." Mm-hmm. So we need to be really mindful of those parent patterns, and I use this metaphor with families because what this does is opens that loop for the caregivers to understand, oh, I do have a role in this, and it's learning skills.
It's learning how to respond differently. It's not quick phone calls and long emails where I'm exchanging information with the therapist, but it's me doing my own work, and that's something that I have found as the parent of a teenager and also as a teen therapist that is so important and probably one of the, the biggest gifts you can give to your, you know, clients or, and/or teen child is like how do I do my own work so that I show up wholly for them rather than reacting to my own stuff?
Gordon Brewer: Yeah, I couldn't, couldn't agree more. I, it's, um- Yeah. It's, that's- that's key to really do any of this effectively, is to do your own work. It's just, you know-
Katie K. May: Absolutely ... that's just me. As a therapist too, I think. Well, yeah. So we're not responding, which is another piece of, with these high-risk clients, therapists can get very anxious.
You know, may hospitalize prematurely, may make decisions because they worry about liability or risk. So I think that self-regulation piece is just very important all around. Yeah.
Gordon Brewer: So, uh, how do you address, you know, like, uh, high-risk behaviors or- ... you know, safety concerns and that kind of thing?
Katie K. May: Yeah. So there's several things that I do to proactively address safety. Number one, if a teen is coming in with any kind of self-harm behaviors or past suicide attempts, I'm not waiting until something happens again to assess past patterns, because we know, whether it's in the- the workplace or in the therapy room, past behavior predicts future behavior.
So I want to know, what was the first time you self-harmed? What was the most intense time you self-harmed? What was the most recent suicide attempt? I'm starting to build patterns with them and look for, what are those common triggers? Maybe they're relational triggers, so that's where we need to start.
Maybe it's- Mm-hmm ... you know, some sensory need that they have that isn't being met. So we're looking for past patterns, and we're putting in place what I call the teen support person safety rating scale. So this is a safety plan, but it looks at, what am I doing when I'm calm? What am I doing when I'm a little bit activated?
What am I doing when I'm completely flooded, and I don't even have the words to say how I'm feeling? And what I think is the most important piece of this, 'cause there's so many parts that we could get into, is- Mm-hmm ... there are two columns in this plan. One is, what would others see when I'm at, when I'm in this level, and what do I want them to do to respond to me?
'Cause we're always coming back to that parent-teen dynamic. And so I'll give you an example. My child, when- when they got overwhelmed, they would cover their head with a blanket, and I would go, "What's wrong? What do you need from me?" Right? All the questions we're not supposed to ask, because I'm imperfect and I'm a parent and I'm not in my therapist brain- Mm-hmm
in those places. Yeah. And so what I learned over time was that bringing them a drink and sitting beside them and saying, "I'm here, and if you wanna talk, great. If not, I'll just sit here with you." So we teach this process to parents as well, for teens to be able to say, you know, when I'm at a three out of three on my scale and I'm completely overwhelmed and I say, "Leave me alone," and I maybe say it in a tone that you don't like, what I actually need is for you to really leave me alone and let me go to my room and calm down, and not follow after me, because that's gonna make me feel worse, and that's gonna blow up, and then I'm gonna threaten suicide.
So we start to look at these patterns and interactions so that the next time something happens, there's already a plan in place.
Gordon Brewer: Yeah. So y- do you find that parents are, are pretty open to that? I mean, as far as not trying to micromanage and that kind of thing, or do you find that, uh, some parents are just, the- those patterns are so ingrained that they just-
Katie K. May: Mm-hmm
yeah. I would say 80/20, Gordon. Like Yeah, yeah ... 80% of parents are like, "I'm tired. We've tried it all. I'm willing to try something differently. That's why we're here." And to be honest, most of those te- parents have a teen that's been in crisis or, or they're at risk of some very dangerous life-threatening behavior, so they're willing to do what it takes.
Mm-hmm. And then about 20% of parents, I think are so wounded by their own experience of being parented or holding their own stuff that they require a little bit more support to get to the place of being open and willing to take ownership of their part. I like to, when I teach this to other therapists, I always joke and say, I like to break parents and put them back together.
But that's like the, the joking way that I say that what I'm really looking for is a core fear that they have. So if they're defensive, if they're angry, if they're judgmental, what's below that is some kind of fear. I'm gonna lose my child. I'm gonna lose a sense of loyalty I have to my family of origin.
I'm going to, you know, whatever that fear is for them, we wanna get under the surface and really get them to understand where it's coming from for them. And once we get them there, and typically there are some tears, and that's the breaking them- Yeah ... and putting them back together. Right. But then they understand, oh, I am holding something that requires work in order for this to change.
Gordon Brewer: Yeah. So as y- as you have began putting all this together, and I, I would think it's taken you years to kind of put this- Over a decade ... framework together and seen it work and tried it out and that sort of thing, walk us through the different, um, the different parts of this. You know, from the start to finish.
And then also we wanna be sure and talk about your book, so, because I think a lot of people- Yeah ... are gonna be interested in that, yeah.
Katie K. May: So I think the, the answer is the same, 'cause walking through the process also looks like walking through the chapters of the book, so I'll talk you through.
Uh-huh. We start with that intake where caregiver and teen are included. We start to understand the, the patterns beneath the surface, so looking at behavior as communication and understanding what that behavior is, and that means looking at past patterns. That means understanding what those patterns mean and what that behavior is trying to communicate.
And we're really, what we're looking for is how is this problem that we're seeing on the surface actually a solution for an underlying emotional need or underlying emotional dysregulation that's happening? We are looking at life worth living goals. We're helping the teen activate a vision of what does the future look like when I don't have these big and overwhelming emotions.
Essentially, like, why am I doing this and what am I doing this for? We're bringing caregivers into the process with a caregiver-only intake, and then these consistent caregiver touchpoints that have a very structured way of looking at, like, what's working, what's not, what do you need to stop or start doing.
We're aligning teen and caregivers on treatment goals, and so that means that we ha- we have to agree, all of us, that we're working on the same thing. So I'm not gonna work on parent's desire for a teen to get straight As when teen is also wanting to die and not go to school every day. We have to agree on the same problem to work on, you know, one to, one to three problems at a time.
And then we have a very specific session structure that brings the client through what happened in their week, what did they practice, what worked, what didn't work, and then what are we working on today based on what happened in your week. For ex- we use a diary card- Mm-hmm ... which is like a tracking tool.
And so for example, if a client self-harmed, we would be doing something called a behavior chain to assess that self-harm in that session. If that didn't happen, we might do something else in the session. But we have a structure to identify what's important, what to work on, and then how to take what's worked on in session and bring it into the client's week so they're actually practicing.
And like one of the things therapists will say a lot is like, "My clients know the skills, but they're not using them in their everyday life." This is the process for how we get them to actually use skills in their everyday life. Mm-hmm. And then some of the final pieces of that are, are the safety planning, the proactive safety planning, helping parents learn how to assess for safety at home and make the home environment safer.
And then therapist sustainability, because this is really hard work, and it's- Right ... really heavy work. And so having a consult team of other therapists who do this work, understanding how to ask for help, what those signs of burnout look like is really that final piece in the framework so that you can keep doing this work.
I love this work. I've been doing it for over 12 years. Mm-hmm. And I will say in terms of clinical work, I've never felt burnout because I feel like I have a solid process for how to do the work but also how to measure my effectiveness in the work- Mm-hmm ... which I think is, is really important. Like I don't measure my effectiveness or worth as a therapist on whether or not my clients feel better when they leave my office.
So having that, the measuring metrics for how this work is done is part of that therapist sustainability.
Gordon Brewer: Yeah, what are some of the parts of that me- of those metrics? I mean, You know, I always, I, I like metaphors, and I always tell people that I supervise, you never know what seed you're gonna plant because-
Katie K. May: Yeah
Gordon Brewer: stuff comes back later, you know, and they remember it. So yeah, but
Katie K. May: anyways. Yeah, absolutely.
Gordon Brewer: Yeah.
Katie K. May: So I was... I like this process, and it's the same process that we use with, um, new therapists that come into my practice that we train. And I'll always say, like, when you're getting feedback, it's not subjective.
It's not what I think that you should do. It is an audit form of the, the things that make this therapy effective. So some examples might be, did I start the session by reviewing what happened in the week, whether that's a verbal review, a diary card, or some other way, and did I use that information to set the session agenda and ensure that we're talking about the most, the highest priority targets first?
So that would be one thing. Mm-hmm. Like check, did I do that? Did I not do that? And one of the reasons that's important, I always come back to structure when we're looking at was the session effective, because we've all had those sessions where a client will talk about a friend issue, a frustration with parent, and then in the last five minutes they'll say, "Oh yeah, and I had a suicide attempt," or, "Oh yeah, and I'm experiencing ideation."
Mm. And so this is one of the ways, especially with high-risk teens, that we're able to organize treatment to prioritize things that are gonna keep them alive and keep them in treatment.
Gordon Brewer: Mm-hmm.
Katie K. May: So it's things like that we look at. Did I use these validation strategies? Was I sure to identify how their behavior made sense in the context of their life?
Um, did I, was I validating but also did I, was I directive when I needed to be? Mm-hmm. So we have these, these metrics that therapists can check off and say, "Oh, I did that. Oh, I did that." So even if a client leaves session and they're still feeling really heavy and sad, which we know is the case with chronically depressed c- clients, they don't get, they don't get happy quickly, right?
No. So we need these other ways to reinforce that the work is still effective.
Gordon Brewer: That's g- that's great. Um, yeah, because I think it's incremental s- you know- Exactly ... incremental change. Yeah. Yeah. So if you were to... And I, I don't, I... This might be a hard one to answer, but it's something that always gets me curious.
If, if you could kinda name the theme of the, the bottom line kinda underlying problems for teens, what would you say that is?
Katie K. May: Oh, it's, it's not a hard question as must- as much as I think it's a complex question. I'm gonna answer it. Yeah. But I think the answer differs. Like, my, my response is typically to assess and understand specifically for the client or person what the barriers are or what's getting in the way of them being more skillful or moving forward.
But if I were to generalize, I'll, I'll answer in a general sense. Yeah,
Gordon Brewer: yeah, yeah.
Katie K. May: I, I think it's, for the teens that I work with, like biologically sensitive teens, it's an overwhelm of their own emotional state that creates a skills breakdown point. So the inability to use a coping skill, the inability to advocate for themselves, to skillfully ask for help or ask for space.
And, and to me that comes from, they have this almost like their emotions are a fire that's burning them up inside, and so every decision becomes an impulsive way to put the fire out rather than skillful, because when you're on fire all you want is to put that fire out.
Gordon Brewer: Right. Yeah. Yeah. I'd I'd always wondered if, um, if it has a lot, if it's...
A- and you, that, I'm just I'm curious about this because I always had this, um, idea that people need to be connected- Mm ... with others, and I think I think about even when I was a teen, I felt like I was a lonely kind of teen.
Katie K. May: Yeah.
Gordon Brewer: And do you think that plays a big part in it, is just the not feeling understood, not feeling seen, that, that kind of thing?
Katie K. May: Absolutely. I think that- Uh-huh ... the ideas of connection and validation are critical to most humans, especially in those teen years when peers become so much more important, and belonging becomes so important. And so- Mm-hmm ... yeah, I would absolutely say that's a factor.
Gordon Brewer: Yeah. Yeah. Awesome. Awesome. Katie, I've gotta be mindful of your time in all of this, and, uh, tell folks about your book, the title, and how they can find it, and how they can get in touch with you and that sort of thing.
Katie K. May: Yeah, for sure. So my new book is called Teen DBT in Practice. It's a comprehensive guide for a therapist treating high-risk teens. The best place to find me is katiekmay.com. You'll find links to both of my books, to my training program, to my counseling website. Anything that you need, it's kind of like the hub for all things me, so katiekmay.com.
Gordon Brewer: Awesome, and we'll have links in the show notes, in the show summary and all of that for people to find it easily. So, well, Katie, it's always great to talk to you, and I, this was a lot of fun.
Katie K. May: Thanks so much, Gordon. It was great to see you.
Gordon Brewer: Yes. Hopefully we'll have you back here soon.
Katie K. May: I'm ready.
Gordon Brewer: Take care.
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Teen DBT in Practice: A Comprehensive Guide for Therapists Treating High-Risk Behaviors
How to Assess Teen Suicide Risk
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