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Sunnybrook psychiatrists are helping teenagers understand  why they are bullied and how they can break the cycle of harassment.

Illustration by Steve Adams

When David* came to Sunnybrook, he was quick to tell his psychiatrist that his classmates were bad people. His classmates threw things at him on the bus to and from school, the 16-year-old said; they relentlessly called him names in the schoolyard, and he felt like he couldn't contribute to classroom conversations without snide comments being whispered behind his back. The bullying caused him such anxiety that he routinely took himself out of social situations, and his parents sought help at Sunnybrook

Dr. Gili Adler Nevo, staff psychiatrist in Sunnybrook's Division of Youth Psychiatry, set to work on guiding him out of his distress – and that included understanding whether David's own behaviour was unintentionally attracting the attention of bullies.

"This does not place any blame on the victim at all; on the contrary, it empowers them," says Dr. Adler Nevo. "The fact that bullying – degrading another human being – is wrong is clear cut and there are no two ways about it. That is the bully's responsibility, but any therapy operates on the understanding that no human being is perfect. It's not the victims' fault and they're not to blame, but you always need two to tango. For every two people there's an interaction."

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Bullying is a hot topic in the media due partly to tragic cases that have ended in suicide. Bullying is common enough to cause concern; Public Safety Canada reports
that 10 per cent to 13 per cent of boys and 4 per cent to 11 per cent of girls in grades 6 to 10 reported being bullied at least once or twice a month. Bullying may not be necessarily worse than it was 30 years ago, but we hear more about it due to better communication and a better understanding of the lasting damage it can have on a
teen's social development.

And so school boards have scrambled to adopt zero-tolerance policies. They've established approaches to address the bullies and programs aimed at teaching students how they can help quash bullying when it arises. These approaches are essential, Dr. Adler Nevo says. But there's an equally important angle: the victim. Dr. Adler Nevo is one of several Sunnybrook psychiatrists focused on care for the victim – addressing the connection between bullying, depression and anxiety so that the victims don't fall through the cracks.

The victim, not the crime

"What is missing from the picture is treatment for the bullied themselves," she explains. "The systemic problem should be addressed and the bully treated, but the one who needs the most help is the victim."

She points to research that shows bullied children often continue to be harassed even after they change schools, for example, and that factors such as appearance, ethnicity and disabilities don't determine whether a student is bullied. Bullies are drawn to those who lack a social group – and that often includes teens who suffer anxiety or depression. Her treatment focuses on helping bullied teens understand the role they have in the dynamic in the hopes of breaking the cycle.

"Take a teen starting high school. He or she may have anxiety, and think: 'Nobody is going to like me, and I'm not going to have any friends. I'm going to be awkward.' So the teen sticks to the wall, and really does seem awkward, and the people around him feel that and react to it," explains Dr. Adler Nevo. "Inside the teen could be all these wonderful things, but the way he or she behaves could deter people from approaching."

Through support, understanding and validation of what they're feeling, Dr. Adler Nevo helps her patients develop insight into how their thoughts, emotions and behaviour influence how others perceive them, she says. Since teens who remove themselves from regular social interactions tend to be prime targets for bullies, finding a way to become social again is key.

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Though she won't divulge her entire approach (her therapy works best when it's a journey for which the teen oesn't have a roadmap, she says), it's a customized cognitive behavioural therapy that includes Prolonged Exposure, traditionally used to treat post-traumatic stress disorder patients.

By encouraging real-life but safe exposure to events that trigger anxiety for the bullied teens – which could include simply going to school – teens learn to engage with and process the traumatic event. It helps them understand their anxiety, but not become limited by it.

"Therapy validates their emotions, but it also helps move forward," Dr. Adler Nevo explains. "They gain a stronger sense of self-efficacy, which means they have a stronger sense that they can do something about their situation. They can change it."

The approach worked for David, the 14-year-old convinced his classmates were horrible. The worst-offending bullies were spoken to by teachers, but David also made personal progress by understanding little by little how his anxiety was affecting the way he was viewed by others.

"That sounds simple, but it's really tremendously difficult. Imagine yourself a teenager, feeling fragile, thinking you need to be macho, strong and having to acknowledge your anxiety in order to move out of it. Many of the victims would rather deny," she says. "Therapy was a combination of working internally on thoughts and feelings, seeing where they make sense and where they are unhelpful for him, where they're not, and actually changing the way David approached his peers."

And when David was asked about his classmates toward the end of treatment? "They're actually ok," he said.

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Bullying and depression

A U.S. study published in Child Development in March found that the relationship between bullying and depression is not straightforward. While parents and teens may assume their depression is the result of bullying, the study showed it's often the other way around – that depressed teens sometimes attract unwanted attention.

"Bullies have radar for kids who are going to be targetable – who are not going to fight back," explains Dr. Elyse Dubo, a staff psychiatrist who treats depression in
youth. "Kids with depression can be targeted because they look like they have low self-esteem, and are somewhat withdrawn."

To make matters worse, depression in teens can come with an unfortunate symptom, she says: rejection sensitivity. These teens view every social interaction as negative; they see two friends talking and are so self-conscious they assume it's about them and think their friends don't want to be around. Their relationships dwindle, setting them up as prime targets for bullies.

"The teens often start to isolate themselves and won't sit with their friends at lunch because they think their friends don't want to sit together, or they won't return calls
because they think their friends don't really want to talk to them," Dr. Dubo says. "They find themselves completely isolated, making them easy targets for bullies. These
kids feel so socially fragile and they can so easily feel devastated because of their depression that it's hard for them to gain perspective."

Just treating the depression itself can have remarkable results. Dr. Dubo has seen extreme cases where the right medication helped get both the depression and the bullying under control within a few weeks.

"As we treat the anxiety and depression with medications and therapy or both, they improve in their symptoms," explains Dr. Dubo. "As the depression improves, their self-esteem improves. Their perception changes, so they're not seeing things so negatively and they can start to take risks socially. As they get out of their depression, they feel like they can start to reach out and start new social interactions."

It's not always that simple, of course. Long-term depression and anxiety can have detrimental and complicated effects on a teen's development that need to be addressed. In those cases, it may take much lengthier therapy to help the teen undo his or her negative thinking patterns and behaviours that have developed as a result of their anxiety and depression. Dr. Dubo is also quick to emphasize the importance of grass-roots educational programs in the school system aimed at bullies, as well as those who may be unwilling participants in the dynamic. But she also points out that helping teens understand their role in the bullying is an important part of the overall picture.

"By telling these kids there's something they can do to stop this from happening, we're giving them a sense of power," says Dr. Dubo. "If we say, 'It's all the bully's fault,' then the kid has absolutely no power in this. So we validate their experience and acknowledge how hard it's been for them – and absolutely that what the other kids are doing is not right – but then you collaborate around ways that they can shift out of this."

The bully cycle

To be sure, the depression-bullying can cause a downward spiral, psychiatrist Dr. Amy Cheung says. Many of the bullied teens she treats have depression or anxiety that was previously undiagnosed. Their moods are hurting their ability to maintain relationships, and having strong relationships is key to avoiding being bullied, she notes. Being bullied worsens their depression, and the cycle continues.

"I think removing the bully is one thing. The tougher situation is making sure that some other kid doesn't become the bully because this person has no friends and they're an easy target for the bully," says Dr. Cheung. "If you're in a good group of friends, it's more difficult to be bullied."

As well as anxiety and depression therapy, her treatment includes interpersonal therapy, which helps teens understand that their moods affect their relationships and vice-versa, all with the goal of building a social network.

"It's all about building emotional support. We count the positive relationships in their life, and sometimes kids don't realize all the people who are out there to help them," says Dr. Cheung. "It's a therapy that teens really like, because teens are all about their relationships."

Dr. Cheung teaches her patients that bullying isn't out of their control. Her approach doesn't place blame – and it certainly doesn't negate the need for zero-tolerance programs or punishment for bullies themselves – but it does acknowledge that they're inadvertently feeding into the dynamics of the bullying relationship.

She points to Steven, a teen who'd been bullied for years. Through the course of his therapy with Dr. Cheung, he came to admit that he didn't have many close friends.

"His success came through interpersonal therapy. He realized he does need relationships and people who are supportive of him – not just superficial friends – and that he needs to work on some of those relationships," says Dr. Cheung. "Treating his depression will mean he will be well enough to want to try to make friends, and build a support system so that he will not be the target of bullying anymore."

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