Evidence-Based Reviews

Adapting dialectical behavior therapy to help suicidal adolescents

Current Psychiatry. 2011 March;10(3):18-34

Including the family, other changes increase DBT’s efficacy for these patients

References

1. Barbui C, Esposito E, Cipriani A. Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies. CMAJ. 2009;180:291-297.

2. Dubicka B, Hadley S, Roberts C. Suicidal behavior in youths with depression treated with new-generation antidepressants: meta-analysis. Br J Psychiatry. 2006;189:393-398.

3. Hammad TA, Laughren TP, Racoosin JA. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry. 2006;63:332-339.

4. Katz LY, Kozyrskyi AL, Prior HJ, et al. Effect of regulatory warnings on antidepressant prescription rates, use of health services and outcomes among children, adolescents and young adults. CMAJ. 2008;178:1005-1011.

5. Brent DA, Kolko DJ, Wartella ME, et al. Adolescent psychiatric inpatients’ risk of suicide attempt at 6-month follow-up. J Am Acad Child Adolesc Psychiatry. 1993;32:95-105.

6. Pfeffer CR, Klerman GL, Hurt SW, et al. Suicidal children grow up: rates and psychosocial risk factors for suicide attempts during follow-up. J Am Acad Child Adolesc Psychiatry. 1993;32:106-113.

7. Granboulan V, Roudot-Thoraval F, Lemerle S, et al. Predictive factors of post-discharge follow-up care among adolescent suicide attempters. Acta Psychiatr Scand. 2001;104:31-36.

8. Miller A, Rathus JH, Linehan MM. Dialectical behavior therapy with suicidal adolescents. New York NY: The Guilford Press; 2007.

9. Lynch TR, Trost WT, Salsman N, et al. Dialectical behavior therapy for borderline personality disorder. In: Nolen-Hoeksema S, Cannon TD, Widiger T, eds. Annual review of clinical psychology. Vol 3. Palo Alto, CA: Annual Reviews; 2007:181-205.

10. Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav. 2002;32(2):146-157.

11. Woodberry KA, Popenoe EJ. Implementing dialectical behavior therapy with adolescents and their families in a community outpatient clinic. Cogn Behav Pract. 2008;15:277-286.

12. James AC, Taylor A, Winmill L, et al. A preliminary community study of dialectical behaviour therapy (DBT) with adolescent females demonstrating persistent, deliberate self-harm (DSH). Child Adolesc Ment Health. 2008;13:148-152.

13. Katz LY, Cox BJ, Gunasekara S, et al. Feasibility of dialectical behavior therapy for suicidal adolescents inpatients. J Am Acad Child Adolesc Psychiatry. 2004;45:276-282.

14. Sunseri PA. Preliminary outcomes on the use of dialectical behavior therapy to reduce hospitalization among adolescents in residential care. Resid Treat Child Youth. 2004;21:59-76.

15. Trupin EW, Stewart DG, Beach B, et al. Effectiveness of a dialectical behaviour therapy program for incarcerated female juvenile offenders. Child Adolesc Ment Health. 2002;7:121-127.

16. Linehan MM. Validation and psychotherapy. In: Bohart AC Greenberg LS, eds. Empathy reconsidered: new directions in psychotherapy. Washington, DC: American Psychological Association; 1997:353-392.

17. Linehan MM, Armstrong HE, Suarez A, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48:1060-1064.

18. Trautman PD, Stewart N, Morishima A. Are adolescent suicide attempters noncompliant with outpatient care? J Am Acad Child Adolesc Psychiatry. 1993;32:89-94.

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Dr. Salsman: Teaching suicidal adolescents skills for ‘walking the middle path’

Treating suicidal adolescents is fraught with challenges. Antidepressants may be associated with increased suicidal ideation in adolescents,^1-3 although some data suggest that increased adolescent suicide rates are correlated with decreases in antidepressant prescribing.⁴ Adolescents hospitalized after a suicide attempt are likely to attempt suicide again after they are discharged.^5,6 Such patients might not attend outpatient psychotherapy; a study of 167 adolescents discharged after a suicide attempt found that 26% never attended follow-up appointments and 11% went once.⁷

Emerging research supports the effectiveness of dialectical behavior therapy (DBT) for suicidal adolescents. DBT is a form of cognitive-behavioral therapy that combines individual therapy, skills training, and telephone coaching and is implemented by a therapist consultation team that meets weekly. This article reviews evidence supporting the efficacy of DBT for suicidal adolescents and describes principles of outpatient DBT for these patients as developed by Miller et al.⁸

Evidence of DBT’s effectiveness

A review of DBT research found strong evidence for DBT’s effectiveness for suicidal adults.⁹ Recently, DBT has been adapted to treat adolescents with suicidal behavior and nonsuicidal self-injury (NSSI).^10-15

In a nonrandomized trial, Rathus and Miller¹⁰ compared 29 suicidal adolescent outpatients receiving DBT with 82 participants receiving treatment as usual (TAU). Patients were assigned to DBT if they had a suicide attempt in the previous 16 weeks and ≥3 borderline personality disorder (BPD) features or to TAU if they met only 1 of those conditions. Patients in the DBT group had more axis I disorders and pretreatment hospitalizations than the TAU group. Compared with those receiving TAU, patients treated with DBT had fewer hospitalizations (13% in TAU vs 0% in DBT) and a lower dropout rate (60% in TAU vs 38% in DBT). The DBT group experienced significant reductions in suicidal ideation, BPD symptoms, and general psychiatric symptoms. There was 1 suicide attempt in the DBT group vs 7 attempts in the TAU group; however, this difference was not statistically significant.

Clinical Point

In a nonrandomized trial, adolescents treated with DBT had significant reductions in suicidal ideation and other symptoms

Woodberry and Popenoe¹¹ examined the use of DBT for suicidal adolescents and their families in a community outpatient clinic. Adolescents reported reductions in overall symptoms, depression, anger, dissociative symptoms, and urges for intentional self-injury. Parents reported reductions in their children’s problem behaviors and in their own depressive symptoms. In a study of DBT in 16 adolescent females with chronic intentional self-injury, patients reported significant reductions in incidents of intentional self-injury, depression, and hopelessness, and increases in overall functioning.¹²

Three studies have examined using DBT for suicidal adolescents in residential facilities. In a pilot study, Katz et al¹³ compared DBT with TAU for 62 suicidal adolescent inpatients. At 1-year follow-up, both groups experienced significant reductions in suicidal ideation, NSSI, and depression. However, compared with those who received TAU, DBT patients had fewer behavioral problems during hospitalization. Sunseri¹⁴ used DBT to treat adolescent females in residential treatment. After DBT was implemented, residents were hospitalized because of NSSI and suicidality for fewer days than before DBT. Trupin et al¹⁵ taught DBT to staff who worked with female adolescent offenders at a juvenile rehabilitation facility. After the staff implemented DBT, the rates of problem behaviors and punishment by staff decreased on 1 unit; there were no behavior or punishment changes on another unit.

Clinical Point

DBT attempts to synthesize acceptance with the change-based strategies of behavioral science

Theoretical foundations

Biosocial theory. The problems DBT treats in suicidal adolescents include emotion dysregulation, interpersonal conflict, impulsivity, cognitive dysregulation, and self-dysregulation.⁸ The biosocial theory postulates that these problems are the result of the transaction, or reciprocal relationship, between biologic predispositions and an invalidating environment. The biosocial theory suggests 3 biologic characteristics often are found among suicidal adolescents:

high emotional sensitivity
high extremity in reactions
a slow return to baseline after experiencing a surge in affect.⁸

Although these characteristics indicate higher emotionality, they are not sufficient to account for suicidal adolescents’ difficulties. Problems arise when individuals with these biologic characteristics are raised in an invalidating environment, where the adolescent does not learn how to regulate emotions. Common characteristics of invalidating environments and their effects on adolescents are described in Table 1 .⁸

Treatment theory. DBT for suicidal adolescents focuses on a synthesis between 2 seemingly opposite treatment strategies: change and acceptance. The change focus is derived from behavioral science, and treatment incorporates standard behavior therapy practices, including chain analysis (described below), skills training, contingency management, and exposure.