Adapting Dialectical Behavior Therapy to Help Suicidal Adolescents: Including the Family, Other Changes Increase DBT's Efficacy for These Patients

Article excerpt

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)

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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 Miller (10) 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 [grater than or equal to]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.

Woodberry and Popenoe (11) 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 al (13) 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. Sunseri (14) 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 al (15) 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.

Theoretical foundations

Biosocial theory. The problems DBT treats in suicidal adolescents include emotion dysregulation, interpersonal conflict, impulsivity, cognitive dysregulation, and self-dysregulation. …